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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.
. III. Standards on Access and Continuity of Care. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified.also is the medication management and the family rights. There are seven (7) criteria that guide the nurses regarding the importance of access to care. These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. IV.
organization and controlling functions of the nursing service administration and their relationship with other services.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. There are seven (7) criteria included. There are two identified criteria under this component. professional standards and institutional requirements. Standards on Human Resource Management . It The second part is the Administration and Management. accountability and authority of nursing administration. Standards on Nursing Documentation . This concerns managing the nursing services in the hospital. direction. 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. need for organizational structure which will delineate responsibility. and clinical based on applicable laws and regulations. These focus also on planning. which include documentation of significant data both structure. This chapter recommends the . Standards on Governance and Direction . V. There are five (5) standards identified: I. II.
Standards on Quality Improvement . Standards on Communicati on Management . Standards on Facility Management and Environmental Safety .also includes staffing modalities depending on the type of services. . This standard contains three (3) criteria and covers environmental safety IV. III. It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective. This standard has three (3) criteria which address the need to institutionalize V. Three (3) criteria are identified focusing on the patient’s record. administration record and communication of information.
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. .
plan of care. Measurable Elements 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. individual needs or (e. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following: 1.2. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. Psychological •Knowledge level •Language spoken •Barriers to learning 1. erval appropriate to patient’s condition.1.g. 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. 1.0. Those responsible for direct nursing care prioritize patients’ needs based on assessment results. Pain is . 2. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me.
skilled care facility •Individual who will accompany the patient home (name.7. Vital signs 1.5.Preference and idiosyncrasies 1. Elimination Pattern 2. Self – Concept Pattern 2. There is an established screening criteria according to patients’ functional capacity and needs like: 2.Coping – Stress Tolerance Pattern 1.8. relationship) 2.1. Nutritional status.2. Spiritual •Religion 1.6. Nutritional – Metabolic Pattern 2.Discharge plan •Place: home.7.10. Activity – Exercise Pattern 126.96.36.199.5.4.8. Pain assessment 1.• Sensory assessment 1. telephone number. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2.11.9. Cognitive Pattern . address. Sensory – Perceptual Pattern 2. Sleep – Rest Pattern 2. Economic factor •Financial barrier 1. Role – Relationship Pattern 2. Sexuality – Reproductive Pattern 188.8.131.52. extended. Social •Cultura l concerns 1. needs and risks 1.
Lack of mobility 5. Age 5. technique and instruments. but are not limited on the following: 4.Value – Belief Pattern 3. Assistance with activities of daily living 5. 5. Measurable Elements 1.Referral for continuity of care as necessary II.1.2.2. 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: 5.3. There are existing policies and procedures on care process developed by those responsible for governance which include .5. Continuing medical and nursing needs 5. Other pertinent data are collected using the appropriate assessment. 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. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care.11.4.
9.12.4. prevention of illness.g. 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. Care of patient in restraint 1.1. 6.10. Care of comatose patient 1. Care of patient on chemotherapy 1.5. Patient participate in planning of care taking into consideration the cultural.11. Care of immune . Care of patient receiving blood and blood components 1. 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: . 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. Care of patient receiving medications with narrow margin of safety 1. 1. Care of patient with communicable diseases 1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2. Measurable Elements 1. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e.13. The care plan ensures that priorities of care are established.8. 3.7. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. alleviation of suffering and restoration of health. 1. Care of perioperative patient 1. Measurable Elements 1. 5. religious and other beliefs of patients. The care plan is documented in the individual patient’s record to promote continuity of care. There is an evidence that family and significant others are involved in the planning process.15.1. ventilatory equipment) Care of patient on dialysis (hemodialysis. 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. •Disabled 1.1. The care plan is updated as appropriate based on the reassessment made. 1. Care of patient on nutritional therapy 184.108.40.206.suppressed patients 1.6. 2. Care of patient in pain 1. 4.
Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess.g. 1.1.Code of Ethics for Nurses 1. 2. Ten (10) Golden Rules in Drug Administration 1. Evidence . It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations. 4. 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. There is an existing pain management guideline for nurses to appropriately assess. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record.1. monitor.3. evaluate and manage patients in pain. There is an evidence that patient’s responses to interventions are documented. 2.5. Measurable Elements 1. 3. .2. Scope of Nursing Practice as provided by law and all relevant legislations (e. evaluate and manage patients in pain. monitor.based practice 1. There is evidence that patients receive care according to pain management guidelines. Standard IV: Evaluation of Care Measurable Elements 1. The revision in care plan if any is reflected in the patient record. Patient Bill of Rights 2.6. 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 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.4.
Emergency Drugs 1. Endorsing (especially high valuable drugs) 1. procedures and guidelines on medication management for symptomatic. Standard VI: Medication Management The Nursing Services Department has established policies. 1. Assessment.4. psychological.Medication Recall System (Expired or Outdated Drugs) 1. 2. Advance directives Do Not Resuscitate.9. 1.10. and palliative treatment of patients’ diseases and for safe nursing practice. Pain assessment. are monitored and recorded.3. .4. There are existing education and training programs for nurses on pain management.220.127.116.11. Measurable Elements 1. Waiver. Pastoral services are provided based on the spiritual beliefs of the patient and family. procedures and guidelines on medication management which include but are not limited on the following: 1. 2. rules and regulations. Patient and family choices to donate organs and other tissue are supported through provision of relevant information.3. Administering (10 Golden Rules in Drug Administration) 1.2. 1. are respected.1. Living will if any. Carrying out physician’s medication order 1. Respect for patient’s values.Regulated Drugs 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.2. religion and cultural preferences and practices is evident. Monitoring and Storage 1. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident.5.11. Labeling 1. 2. 1. Processes to communicate with and evaluate patients and families about pain are evident. Personal hygiene is rendered based on patient’s need. curative. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment. Preparing 1. In accordance to statutory laws. Documenting 1. There are written policies.8.6. intervention and evaluation.3. Transcribing and ordering 1.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1. preventive. 4.1. The patient’s right of self-determination and choices are respected and accommodated.
Respect for patient’s personal values and beliefs 1. There is evidence that nurses are knowledgeable and supportive of patient and family rights.5.Respect for patient’s need for privacy (e.3. procedure.4. 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. clinical interview.g. There are written policies. 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. treatment.4. A place is designated for the patient’s family to stay.7. Patient’s and family’s beliefs and values 1. vulnerable patients are infants. 2.3. 3.2. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies. Protection of patient’s possessions from theft or loss 1. physical examination. Interventions address patient and family’s psychosocial.g. 1. processes and guidelines that respect and support patient and family rights. outcome of care.2. spiritual and cultural concerns.1. The patient and family are involved in care management and decision. 4. Protection of patient from physical assault (e. 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. Patient’s and family’s educational level . Measurable Elements 1. emotional.1. Measurable Elements 1. children and elderly) 1.6. transport) 1. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. Respect the confidentiality of patient health information 1. Patient’s and family’s literacy 1. III.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration.2. during treatment. 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.3.
Safe and effective use of medical equipment 4. Measurable Elements 1. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1.5.5. Treatment and diagnostic procedures IV. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. Patient’s physical and cognitive limitation 1. Clinical services available 1.1.4. Safe and effective use of medications and their side effects 4. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. Preventing interactions between prescribed medications and other medications (over the counter) and food 4.6. Process for admitting patient or registering out patient 1. Pain management 4. Education resources are available and organized in an efficient and effective manner.4. Patient’s and family’s language 1. 3.5) are available. 4.1. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1. 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. methods and mechanism for education is afforded. When appropriate.3. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. 2.6. Holding area for patient on observation 1. The appropriate structure. it is evident that the patient and family are educated on topics considered high risk to patients: 4. adequate time and communication skills to do so. There is an evidence that nurses who provide education have the subject knowledge. 6. Measurable Elements 1. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients .2. Rehabilitation techniques 4.1.5. 5.3.2. Patient’s and family’s motivations and emotional barriers 1. Criteria for admitting patient or registering out patient 1.7.1 to 4.6. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs.4.
Proposed plan of care 2.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. There is an evidence that staff who responded to emergency patients underwent the necessary training. Limit or overcome barriers such as language. 3. 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. 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. 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. curative. Measurable Elements 1. Expected outcome of care 2. curative. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. 18.104.22.168. Standard V: Continuity of Care In diverse health care setting. 2. Sufficient information to make knowledgeable decision and 2.1. Measurable Elements 1. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. There is an evidence that nurse screening assessment focuses on preventive.Expected cost of care 2. cultural. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. It is evident that criteria is physiologic-based and developed by appropriate individuals. . 4. 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. physical. Measurable Elements 1. 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. There is an evidence that patients with immediate needs/care are assessed. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive.2. 2. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training.
5. 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: 6.6.4. procedures and guidelines regarding the transfer of patient within and outside of the organization.3. Out patient care programs 1. Condition of patient at the time of discharge 6. health organizations or agency. There are criteria that determine patients readiness to be discharged. . out on pass. Medications and treatments 6. Out on Pass.Nursing ward services to surgical and non surgical services 1. 2.5. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge. 3.Nursing ward services to intensive or special services 1.6. There is a process on out on pass patients for a defined period of time.7. and health professionals in the community. Other health care settings 2. 4. Reason for admission 6.Measurable Elements 1. Between nursing units or clinical departments 1. 3.1. referral and follow-up congruent with those of the organization. Measurable Elements 1. There are written policies.1.5. Nursing ward services to diagnostic services 1. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. procedures and guidelines on patient’s discharge. Continuity of care and coordination of services are evident throughout all phases of care.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6. 6. referral and follow-up congruent with those of the organization. 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: 1.8. Significant physical and other findings 6. out on pass. Medications to be taken at home 6.4. During all phases of care. there is a qualified individual.7.2. identified as responsible for patient care and documented in the patient record. Diagnostic and therapeutic procedures performed 6. Standard VII: Transfer of Patient The Nursing Services Department has established policies. Significant diagnosis and co-morbidities 6. Referral for support services to either health care providers. There is a referral system of patients for transfer to other organization. Emergency services to nursing ward admission 1. Standard VI: Discharge.2.9.3.
2.5. Registration number and or Admission number 1.2.8. Transfer of responsibility to another health provider or health care setting is evident.3.The guidelines and procedures include but are not limited on the following: 2. V.4. 2.4. Religion 1.7.3. transferring hospital.1.There is a written policy. 2. civil status 1. Patient’s addressograph – name. stretcher 1. 2. 2.6.9. if any 1. Safe and quality medical transport services within and outside of the organization are provided. Admitted via: ambulatory. Measurable Elements . gender.Measurable Elements 1.6.2. Language spoken 1. wheelchair. 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. Summary of patient’s clinical condition.1. 2. age. Mode of admission/transport/discharge 1. procedure and guidelines on transfer of patient within and outside of the organization.2. 2. Attending physician and referring physician.8. Date and time of admission and discharge 1.4. Formal and informal arrangements are apparent. Advance directive 1. 2. Admitted from: home. care facility 1. Transfer is based on the patient’s needs for continuity of care.4. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. Patient’s transfer is documented.7. Situation when transfer is not possible is stated. Responsible health care provider during the patient’s transfer is identified. interventions (medical and nursing) and continuous care rendered are written.5.1.
Measurable Elements 1. There is relevant/essential. professional standards and institutional requirements. Health history Standard II: Governance Responsibility and Accountability . There is an accurate and complete documentation of patients’ structural data in all nursing and 1.2. Physical examination (head-to-toe) 1.1. 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.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations.
Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I.Health teachings – patient and family 1. clinical planning and services and policy development. social. The Nursing Services governance structure is described in written documents with the approval of proper authority. 4. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.Nursing interventions 1. Psychological.5.4. 3.1.10. .3. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. authority. responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility.Patients’ response and outcome 1. spiritual and economic evaluation 22.214.171.124. The Nursing Services governance structure and processes support professional communication.Actual and potential health problems and needs 1. Measurable Elements 1. 2.Diagnostic and therapeutic interventions 1.Pharmacological management 1.8. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.
Those responsible for governance appoint the Nursing Services Administrator. primarily sets its direction by formulating its vision. Measurable Elements 1. philosophy. Those responsible for the Nursing Services Department governance. Measurable Elements 1. mission. core values and quality objectives congruent with that of the institution and the Nursing profession. 2. The vision. managers. 3. reliable.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. Standard III: Direction-Setting The Nursing Services Department has an established vision. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. 4. philosophy and core values are written ( specific. measurable. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. philosophy. attainable. 2. The governance responsibility and accountability are described in organization’s by-laws. core values and quality objectives congruent with that of the institution and the Nursing profession. mission. Standard II: Governance Responsibility and Accountability . job description and other similar documents. There is a written document that describes how the performances of the governing entity are appraised by specific criteria. mission.
action plan/activities. widely disseminated. Measurable Elements 1. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. updated. resources required and contingencies. interpreted and operationalized. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. 3. Those responsible for governance have established current financial plans and allocation of resources . timeframe. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. nursing manpower and unit operation of responsibility areas. 2. 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. ethical and recorded ).time bound. 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. Measurable Elements 1. reviewed.
and conforms with the applicable statutory laws. 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. 2. Those responsible for governance ensure compliance with the applicable statutory laws. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. The medical supplies. rules and regulations. . Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. 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. Each Nursing Unit has an individual budget plan periodically monitored for variances. 3. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. regulations and standards. 3.2. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. 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. 2. Measurable Elements 1. 4. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Measurable Elements 1. professional and interprofessional relationships and other related endeavors. Measurable Elements 1. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. 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. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers.
II. 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. RA 9173 appropriate education. n such as: fully responsible and 1.4. Nursing Measurable Elements Service Admini strators : .1. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration.1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on. Standards on Human 1.administration courses at the graduate level. Be a member of good standing of the accredited professional organization of nurses. and 1.
Be a regist ered nur se in the Philippi nes. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n.3. with a least nine ( 9) unit s in man age ment and .1.1.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1.2. 1. 1.1. Poss ess a degr ee of bach elor of Scien ce in Nursi ng. 1.
126.96.36.199.1). 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. a n d 1. That for primary hospitals .1. That for chief nurses in .). .A person occupying the position of chief nurse of director of nursing service shall. possess: 1. (1.1.1. and (1. 1.2. in addition to the foregoing qualificatio ns.2.3. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1.2.3) of the above. 1. A master’s degree major in nursing.
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. 2.5. 1.the public health agencies. That for chief nurses in military hospitals. those who have a master’s degree in public health/com munity health nursing shall be given priority. 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). Standard II Staffing Plan : .
Measurable Elements 1. selection. level and modality of care. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. type of services. 3. select. 3. Staff recruitment. type and desired qualification (education. The licensure. Measurable Elements 1. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. 2. patients’ mix. patients’ needs and applicant qualification. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. type and desired qualification of nursing services staff which is written. 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. Those responsible for Nursing Services governance develop a staffing plan that identify the number. reviewed and updated on an ongoing basis.The Nursing Services Department has a staffing plan that identify the number. skills and experience) of Nursing Services staff. Those responsible for Nursing Services governance develop an effective process for gathering. verifying and evaluating the nursing staff credentials. hiring. There are legitimate and legitimized processes to recruit. verifying and evaluating the nursing staff credentials (licensure. 3. hiring. There is evidence of standardized procedure to gather the credentials of all nursing staff. 2. Those responsible for Nursing Services governance consider the organization’s mission. Standard III: Recruitment. education. . selection. hire and appoint nursing services personnel and are uniformly implemented. hiring and appointment are based on institutional. work experience) and other pertinent requirements. Measurable Elements 1. 2. reviewed and updated on an ongoing basis. selection. training and work experiences of nursing personnel are documented and updated. Selection. training. staff and skills mix and other factors affecting the projection of staffing needs. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. education.
3. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. which specifies duties and responsibilities based on established standards of performance. 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. Measurable Elements 1.2. Measurable Elements 1. 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. 2. available resources and staff competencies. 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. Staff placement/assi gnment is based on patient needs.
Functional relationship 1. Accountability 1.specifies: 1. 2. Duties and responsibilities 188.8.131.52. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses. 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. Measurable Elements 1.2. There is evidence of staff development programs for all nursing personnel .
d.throughout the year which include: a. Safety program to protect the patient. c. Resources are available to implement the staff development program such as: . Orientatio n program for newly hired and promoted staff. b. 3. Continuing education. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties. staff and property. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. Career counseling and career advanceme nt/ladder.
regulations and other requirements that are applicable.4. staff and visitors aligned with that of the organization’s master plan.g. Policies and procedures on continuing education staff attendance to staff development programs are evident. (e.1. Measurable Elements 1. Ther e is a wr itten and up-to-date plan. chemicals. plan and budget for upgrading or replacing key components based on facility inspection findings. staff and others. Space and facilities 3. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning.2.3. Objectives of the program 5. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. the Nursing Services Department provides a safe. Those responsible for governance comply with relevant laws.1. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e.4. Measurable Elements 1. Audiovisual equipment 3. Resource speakers 4. Evaluation of the attendees 5. Safety and Security •There is an existing provision for the identification of patient and their families. 3. tampering. .2.3. visitors.g. Title of the program 5.3. For efficient and effective delivery of nursing care and services. radio-active materials and waste. chemotherapeutic agents.6. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2.5. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment. Clinical and clerical staff 3.1.2. 5. Educational resources 3. Medication Room) 1. functional and supportive facility to patients and their families. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1. List of attendees/participants III. Those responsible for governance. destruction or loss.5. Effectiveness of the program 5. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use. Records of staff development program are maintained which include: 5. Program design and content 5.
and that E EThere Documentation and reporting system are are infection surveillance. labeling. processes in a continuous storage. procedures and guidelines on infection control are implemented. epidemics. infectious institutional emergencies. hazardous materials and wastes.7. seven (7) days a week. inventory and 1.hazardous gases and vapors. and recall system. Fire Safety waste). use. Standard III Staff Education 1. electrical failure or interruption and medical gases unavailability. and disasters.6. regular inspection. and medical gases are available 24 hours a day. •A written emergency processes is in place in the event of water interruption or contamination.4.3.policies. •Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. 1. 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. Infection Control disposal of hazardous materials E EThere is evidencewaste. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing. : 1. electrical power. •Monitoring of utilities is evident for .and comprehensive manner to all patient care and staff work areas. • prevention and control programsinvestigation of spills. Utilities •Potable water. 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. preventive maintenance. inventory.
1.purposes of planning and improvement.5. Emergencies •An emergency management plan and processes are evident to likely community/ .
2. There are written policies.clinical staff) VI. Core Values demonstrate their role in the aforementioned safety Procedures.1. procedures. nursing personnel and other health professionals throughout the organization.3. programs. Mission. •Health programs •Process to access care Measurable Elements 1. in-patient or out-patient available 1.2. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs. Circular.3. Clinical record for every patient assessed or •Patient/nursing care services treated. There is an evidence of staff training EMemorandum. E EPolicies. 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. Other Health Professionals (clinical and non. to operate E medical equipment appropriate to their job Activities description. procedures and guidelines on patient clinical record. There is an evidence that the staff can describe andService Philosophy. : : Measurable Elements 1. Standards 3.1. Guidelines. Nursing Personnel E ENursing endorsement in between work shifts 1.4. 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.Community The Nursing Services Department has established •Patient/nursing care services policies.E EEducational materials and methods in an understandable format and language 1. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. 1. Patients and Families 1. Directives. to patients and their families. Security of record •Alternative sources of care and services . Confidentiality of record 1. Vision. E ENursing 2.
Process and frequency of review and continued approval of policies and procedures 2.Review and approval of all policies and procedures before implementation 2. Procedures. Nursing and the Organization 1. Staff Development Programs 1.g. Tracking of policy and procedures in circulation (e.Master Staffing Plan 1.Minutes of Meeting. Control that only current policy and procedures are implemented 2. 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: 1.3.5. authorized person) V.1.9.5.• Protection from loss and destruction and unauthorized access and use 1. Guidelines 1.Quality Improvement Program and other Projects 1. Use and monitoring of standardized abbreviations.6.4.7. procedure codes and definitions 1.2. date of issue. References originating outside the organization 2.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2. Staffing Pattern 1. Nursing Services Department 1. Retention of obsolete policies and procedures 2.1.4. Committees. 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.10.7. Data Integrity •Protection from tampering 184.108.40.206.11.5.3. Bed Capacity and Occupancy Rate 1. symbols. Identification of charges in policy and procedures 2.2. Measurable Elements 1. Standards 1.8.12.Budget Plan 1. title. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. Census of Patients and Diseases 1. Measurable Elements . 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. Organization and Nursing Services Department Policies.
monitoring. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. hand hygiene and barrier technique. processes and results and data are aggregated. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment. Prevention and control measures aligned with International Patient Safety Goals. clinical standards.9.4. 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. 3 . 6. Blood and blood products 1. scientific literature. analyzed and transformed to useful information. . There is a training program for staff consistent with their role in quality improvement and patient safety program. Surgical safety (sterilization/disinfection) 1. 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. Medication safety. Intravenous fluids 1. 4. Infection control.1. clinical pathway) 2. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning.1. Standard III Quality Monitoring. high risk and problemprone processes. 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.6. implemented and monitored for consistent use and effectiveness. surveillance. 2. Measurable Elements 1. Measurable Elements 1. Nursing documentation 1.g.2. reporting (needle stick injury. Medication error 1. guidelines. There is an established reporting system on the quality and safety programs to governance.3. Total parenteral nutrition 1. 3. (e. body fluids and waste segregation/disposal) 1. 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. Standard II Quality Programs : and other relevant evidence – based information. There is a clinical monitoring that exists but is not limited on the following: 1.7. 5.8. Clinical research 1.5.
demonstrate that the improvements are effective and sustained. that includes actions for improvement or changes are planned. the patient’s condition on discharge. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. tested and implemented. or spiritual and social care or service. Credentialing – is the process of obtaining. and other specific . information technology. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. ulation and those in governance and actions taken. and information services. and assessing the qualifications of a health care practitioner like the nursing personnel. scope and severity of the problems. the significant findings. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. Communication Management – is the creation. sharing and disposal of data or information for effective and efficient operation of organization activities. the treatment rendered. psychological. This applies within an organization or across multiple organizations. or nursing care. if any supplies essential to most patient needs (e. level of medical.g. It includes the role of management to produce and control the use of data and information in work activities. the procedures performed.hat exists but is not limited on the following: iagnoses d complaints. elements of care. information resources management. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. use. The process determines if an individual can provide patient care services in or for a health care organization. verifying.
behavioral/mental health institutions.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. or allied health professionals. maintaining quality of care. and alternatives of a medical procedure or treatment before the . and providing for organization management and planning. laboratories and long term organizations. Indicator – is a measure of the performance of functions. over time. nurse. Other names for this group include “board. medications). End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment. This includes ambulatory care centers. Informed Consent – is an agreement or permission accompanied by full information on the nature. Health care professionals are often licensed by a government agency or certified by a professional organization.” and “governing body. group or agency that have ultimate authority and responsibility for establishing policy. Governance – refers to the individual(s).” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. dentist.” “board of trustees.instructions given to the patient or family (for example. It is also known as a “health care institution.” board of governors. and his/her life expectancy is estimated to be within days or months. hospitals. systems. follow –up. home care organizations. risks.” “board of commissioners. This includes a physician. or process.
Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. Plan of Care – is a plan that identifies the patient’s care needs. physicians and other health care professionals involved in the care of patients. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. law or regulation.Robbins. progress notes and discharge summary. applicable licensure. Management. experience. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. Qualification is determined by the following: education. This record is created by nurses. The plan of care may include prevention. 7 Pearson Education South Asia PTE LTD. outlines the criteria for ending intervention. lists the strategy to meet those needs. In-Service Education – is an organized education. registration. habilitation. treatment details. The format of the plan in some organizations may be guided by specific policies and procedures. th Edition. clinical paths or a combination of these. and rehabilitation. practice guidelines. competence. physician or other health care professional begins the procedure or treatment. training. usually provided in the workplace. such as assessment findings. Patient Record/Clinical Record – is a written account of a variety of patient health information. It is based on data gathered during patient assessment. care. S. . or certification. and documents the individual’s progress in meeting specified goals and objectives. Coulter M (2004). documents treatment goals and objectives. protocols. treatment.
opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge. Edition Printed in USA 54321 Noe. Inc. including health care providers. Wright (2004). or process that must be in place for escribe the responsibilities for which t to receive. 3 rd Edition Printed in USA 54321 Joint Commission International (2004). Republic of the Philippines. and Philippine Nurses Association. Metro Manila ctures. The Administration of Hospital Nursing Services in Philippine Department of Health. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). (1999). and other persons. . REFERENCES an organization to provide safe and high-quality care. Philippines. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. Inc. Credentialing. Accreditation Standards for Hospitals. New York Republic Act 9173 or The Philippine Nursing Act of 1991. and service. Fundamental of Human Resource Management. Gerhart. Inc. Edition Printed in USA 54321 Joint Commission International (2004). 1 st Edition Joint Commission International (2008). Association of Nursing Service Administrators of the nursing practitioners are accountable. McGraw-Hill Co. Hollenback. Human Resources for Hospitals. Inc. treatment.
Nursing Administration Handbook. 7 Pearson Education South Asia PTE LTD.M (2004). J (2006). Nurse’s Handbook of Health Assessment. Management. Lippincott Williams & Wilkins th . Coulter M (2004). 5 Edition. 7 th Edition Weber.Robbins. S. th Editi Rowland H & Rowland B (1980). Aspen Publication Tomey A. Guide to Nursing Management and Leadership.
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