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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.
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. 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. .also is the medication management and the family rights. III. IV.
These focus also on planning. accountability and authority of nursing administration. There are five (5) standards identified: I. Standards on Human Resource Management . 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. Standards on Governance and Direction . which include documentation of significant data both structure. It The second part is the Administration and Management. V. This concerns managing the nursing services in the hospital. organization and controlling functions of the nursing service administration and their relationship with other services. and clinical based on applicable laws and regulations.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. There are two identified criteria under this component. professional standards and institutional requirements. direction. This chapter recommends the . Standards on Nursing Documentation . II. There are seven (7) criteria included. need for organizational structure which will delineate responsibility.
It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective.also includes staffing modalities depending on the type of services. Standards on Facility Management and Environmental Safety . III. Standards on Communicati on Management . administration record and communication of information. This standard has three (3) criteria which address the need to institutionalize V. . This standard contains three (3) criteria and covers environmental safety IV. Standards on Quality Improvement . Three (3) criteria are identified focusing on the patient’s record.
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.
Those responsible for direct nursing care prioritize patients’ needs based on assessment results. 1. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me. plan of care. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. 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. 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.1.2.0. Psychological •Knowledge level •Language spoken •Barriers to learning 1. Measurable Elements 1. 2. Pain is . erval appropriate to patient’s condition. 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.
8. Self – Concept Pattern 2.• Sensory assessment 1. Sexuality – Reproductive Pattern 2.8. Cognitive Pattern . Economic factor •Financial barrier 1. Sleep – Rest Pattern 2. Pain assessment 18.104.22.168.6.Coping – Stress Tolerance Pattern 22.214.171.124.Discharge plan •Place: home. needs and risks 1. Nutritional – Metabolic Pattern 2. skilled care facility •Individual who will accompany the patient home (name.10. There is an established screening criteria according to patients’ functional capacity and needs like: 2.Preference and idiosyncrasies 1. extended.10. Nutritional status. relationship) 2. Sensory – Perceptual Pattern 2.4.4. Activity – Exercise Pattern 2. Elimination Pattern 2.6. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2. telephone number.3. Social •Cultura l concerns 1. Spiritual •Religion 1.7. address.5.7. Vital signs 1.9. Role – Relationship Pattern 2.
2. technique and instruments.4. Age 5. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. Measurable Elements 1.Referral for continuity of care as necessary II. 5.3. There are existing policies and procedures on care process developed by those responsible for governance which include . 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.Value – Belief Pattern 3. Other pertinent data are collected using the appropriate assessment.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. Continuing medical and nursing needs 5. Lack of mobility 5.5. but are not limited on the following: 4. Assistance with activities of daily living 5.11.1.
7.1. There is an evidence that family and significant others are involved in the planning process.5. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for.2. 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 in restraint 1.13. prevention of illness. 1. religious and other beliefs of patients. Measurable Elements 1. The care plan is documented in the individual patient’s record to promote continuity of care.suppressed patients 1. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e.14. 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 on nutritional therapy 1.8. Care of patient in pain 1.4.1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2.1.6. •Disabled 1.g. 1. 1. The care plan ensures that priorities of care are established. 2. alleviation of suffering and restoration of health. Patient participate in planning of care taking into consideration the cultural. Measurable Elements 1. Care of patient receiving blood and blood components 1.15. Care of perioperative patient 1. Care of immune . 3. 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: .12. The care plan is updated as appropriate based on the reassessment made. 6. Care of patient on chemotherapy 1.10. ventilatory equipment) Care of patient on dialysis (hemodialysis.3. 5.11.9. Care of comatose patient 1. Care of patient with communicable diseases 1. 4. 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. Care of patient receiving medications with narrow margin of safety 1.
Patient Bill of Rights 2.3. evaluate and manage patients in pain. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. Measurable Elements 1.Code of Ethics for Nurses 1. 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.g. Scope of Nursing Practice as provided by law and all relevant legislations (e. Evidence . 3. Ten (10) Golden Rules in Drug Administration 1.4.6. The revision in care plan if any is reflected in the patient record.1. evaluate and manage patients in pain. 4. monitor. There is evidence that patients receive care according to pain management guidelines. There is an existing pain management guideline for nurses to appropriately assess. 2. Standard IV: Evaluation of Care Measurable Elements 1. .5. 2. 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. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations. 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. 1. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. monitor.1. There is an evidence that patient’s responses to interventions are documented.2.based practice 1.
Labeling 1. are monitored and recorded. 1. Pastoral services are provided based on the spiritual beliefs of the patient and family. There are existing education and training programs for nurses on pain management. Emergency Drugs 1. Endorsing (especially high valuable drugs) 1.2.5. preventive.1. 4. Waiver. 2. procedures and guidelines on medication management for symptomatic. rules and regulations.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1. Personal hygiene is rendered based on patient’s need.6. Living will if any. Administering (10 Golden Rules in Drug Administration) 1. Advance directives Do Not Resuscitate. Monitoring and Storage 1. Preparing 1.9.2.Medication Recall System (Expired or Outdated Drugs) 1. and palliative treatment of patients’ diseases and for safe nursing practice. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. 2.1. religion and cultural preferences and practices is evident. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. In accordance to statutory laws.7. The patient’s right of self-determination and choices are respected and accommodated. 1.10. Carrying out physician’s medication order 1. Respect for patient’s values. There are written policies. Documenting 126.96.36.199. 2. curative. Standard VI: Medication Management The Nursing Services Department has established policies. 1.8. Measurable Elements 1. . Transcribing and ordering 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. psychological. 1.Regulated Drugs 1. Assessment. intervention and evaluation. procedures and guidelines on medication management which include but are not limited on the following: 1. are respected.1. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment. Pain assessment. Processes to communicate with and evaluate patients and families about pain are evident.188.8.131.52.11.
Patient’s and family’s beliefs and values 1. during treatment. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. 4.1. Interventions address patient and family’s psychosocial. The patient and family are involved in care management and decision.4.3.1. Measurable Elements 1.3. physical examination.2.4.Respect for patient’s need for privacy (e. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies. Protection of patient from physical assault (e. Patient’s and family’s literacy 1. 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. children and elderly) 1.2.5. Respect the confidentiality of patient health information 1. There are written policies.6. A place is designated for the patient’s family to stay. 3. 1. transport) 1. III. vulnerable patients are infants. Respect for patient’s personal values and beliefs 1. Patient’s and family’s educational level . There is evidence that nurses are knowledgeable and supportive of patient and family rights. outcome of care.2. 2. treatment.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. Measurable Elements 1. 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. 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. procedure.g.7. Protection of patient’s possessions from theft or loss 1. spiritual and cultural concerns.3. clinical interview.g. processes and guidelines that respect and support patient and family rights. 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. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. emotional.
Preventing interactions between prescribed medications and other medications (over the counter) and food 4. 2. Rehabilitation techniques 4. Patient’s physical and cognitive limitation 1. Holding area for patient on observation 1.5) are available. Treatment and diagnostic procedures IV.1. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. Measurable Elements 1. Patient’s and family’s language 1.1 to 4. Pain management 4. There is an evidence that nurses who provide education have the subject knowledge. The appropriate structure.1. Safe and effective use of medications and their side effects 4.6. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1.2. 6.5.1. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1.3.6. Process for admitting patient or registering out patient 184.108.40.206. Safe and effective use of medical equipment 4. Education resources are available and organized in an efficient and effective manner. 4. When appropriate.4. Patient’s and family’s motivations and emotional barriers 1. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients . 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. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. methods and mechanism for education is afforded. Measurable Elements 1.5.6. Clinical services available 1. adequate time and communication skills to do so. it is evident that the patient and family are educated on topics considered high risk to patients: 4.7. Criteria for admitting patient or registering out patient 1. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. 3. 5.3.4.
.2. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. Measurable Elements 1. 3.3. 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. Limit or overcome barriers such as language. Standard V: Continuity of Care In diverse health care setting. Measurable Elements 1. Measurable Elements 1. physical.5.1. 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.Expected cost 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.4. There is an evidence that nurse screening assessment focuses on preventive. 2. Expected outcome of care 2. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. Sufficient information to make knowledgeable decision and 2. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. 2. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. 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. There is an evidence that patients with immediate needs/care are assessed.Proposed plan of care 2. curative. 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. curative. 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. cultural. It is evident that criteria is physiologic-based and developed by appropriate individuals. 2.
Out patient care programs 1. Reason for admission 6.3.Nursing ward services to surgical and non surgical services 1. Nursing ward services to diagnostic services 1.7.2. Other health care settings 2. procedures and guidelines regarding the transfer of patient within and outside of the organization.1. Significant diagnosis and co-morbidities 6. referral and follow-up congruent with those of the organization. out on pass. Between nursing units or clinical departments 1. and health professionals in the community.8. . procedures and guidelines on patient’s discharge.6.2. There are criteria that determine patients readiness to be discharged. health organizations or agency.Nursing ward services to intensive or special services 1.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6. Measurable Elements 1. Diagnostic and therapeutic procedures performed 6. 3. Standard VI: Discharge. there is a qualified individual. 6. 3. There is a referral system of patients for transfer to other organization.9. Continuity of care and coordination of services are evident throughout all phases of care.Measurable Elements 1. Medications and treatments 6. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge.3. out on pass. Medications to be taken at home 6. Standard VII: Transfer of Patient The Nursing Services Department has established policies.5. Out on Pass.4.1. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. There is a process on out on pass patients for a defined period of time.6. 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. Significant physical and other findings 6. 2.4. 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. 4. Referral for support services to either health care providers. Emergency services to nursing ward admission 1. referral and follow-up congruent with those of the organization.7. During all phases of care. Condition of patient at the time of discharge 6.5. 5. identified as responsible for patient care and documented in the patient record. There are written policies.
2. 2.7. 2. Responsible health care provider during the patient’s transfer is identified.The guidelines and procedures include but are not limited on the following: 2. Mode of admission/transport/discharge 1. procedure and guidelines on transfer of patient within and outside of the organization. Patient’s addressograph – name.6. 2. gender. if any 1. Registration number and or Admission number 1.5. interventions (medical and nursing) and continuous care rendered are written.4. Summary of patient’s clinical condition.2.3. Transfer is based on the patient’s needs for continuity of care.Measurable Elements 1. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. stretcher 1. Patient’s transfer is documented. civil status 1. Advance directive 1. 2. 2. Admitted from: home. Religion 1. care facility 1.4. Date and time of admission and discharge 1.9.1. Attending physician and referring physician.2. Language spoken 1.1. Measurable Elements . transferring hospital.7. Formal and informal arrangements are apparent.2.8.There is a written policy.3.8. 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. 2.4.1. age. 2. Transfer of responsibility to another health provider or health care setting is evident. Admitted via: ambulatory.4. wheelchair. V.6. Safe and quality medical transport services within and outside of the organization are provided.5. Situation when transfer is not possible is stated.
1. Health history Standard II: Governance Responsibility and Accountability .The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations.2. There is an accurate and complete documentation of patients’ structural data in all nursing and 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. Measurable Elements 1. professional standards and institutional requirements. Physical examination (head-to-toe) 1.
responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility.1.4. spiritual and economic evaluation 1.Health teachings – patient and family 1. 3. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.5. . The Nursing Services governance structure is described in written documents with the approval of proper authority. Measurable Elements 1.7. The Nursing Services governance structure and processes support professional communication.3.Nursing interventions 1. 2.6.Pharmacological management 1.Diagnostic and therapeutic interventions 1.8.Patients’ response and outcome 1. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.Actual and potential health problems and needs 1. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. social.10.9. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I. 4. authority. clinical planning and services and policy development. Psychological.
The governance responsibility and accountability are described in a written document to guide how they are to be carried out. mission. core values and quality objectives congruent with that of the institution and the Nursing profession. Standard III: Direction-Setting The Nursing Services Department has an established vision. primarily sets its direction by formulating its vision. philosophy and core values are written ( specific. mission. mission. Measurable Elements 1. 2. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. philosophy. Those responsible for governance appoint the Nursing Services Administrator. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. measurable. The vision. core values and quality objectives congruent with that of the institution and the Nursing profession. Measurable Elements 1. attainable. The governance responsibility and accountability are described in organization’s by-laws. 4. Standard II: Governance Responsibility and Accountability . There is a written document that describes how the performances of the governing entity are appraised by specific criteria. philosophy. 3. managers. job description and other similar documents. Those responsible for the Nursing Services Department governance. 2. reliable.
timeframe. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. updated. Measurable Elements 1. 2. interpreted and operationalized. Measurable Elements 1. reviewed. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. 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 ). action plan/activities. 3. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. widely disseminated. nursing manpower and unit operation of responsibility areas. resources required and contingencies. 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. Those responsible for governance have established current financial plans and allocation of resources .time bound. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives.
Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on 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. professional and interprofessional relationships and other related endeavors. 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. 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. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Those responsible for governance ensure compliance with the applicable statutory laws. Each Nursing Unit has an individual budget plan periodically monitored for variances. 3. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. The medical supplies. and conforms with the applicable statutory laws. 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. 2. 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. rules and regulations. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. regulations and standards. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. Measurable Elements 1.2. 3. 2. Measurable Elements 1. Measurable Elements 1.
Standards on Human 1. Nursing Measurable Elements Service Admini strators : . RA 9173 appropriate education.administration courses at the graduate level. 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.1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration. and 1.1. Be a member of good standing of the accredited professional organization of nurses. n such as: fully responsible and 1.4. II.
with a least nine ( 9) unit s in man age ment and . 1. 1. Poss ess a degr ee of bach elor of Scien ce in Nursi ng.1. 1. Be a regist ered nur se in the Philippi nes.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n.220.127.116.11.
1.2.3. 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 1.1.1.A person occupying the position of chief nurse of director of nursing service shall.1). and (1. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1. a n d 1.3) of the above. That for primary hospitals .1.1.1. . That for chief nurses in .1. 1. possess: 1.4.2.). (1. in addition to the foregoing qualificatio ns.2. A master’s degree major in nursing.
Standard II Staffing Plan : . 2. 1. 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.5. those who have a master’s degree in public health/com munity health nursing shall be given priority. That for chief nurses in military hospitals.the public health agencies. 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).
skills and experience) of Nursing Services staff. 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. patients’ needs and applicant qualification. type and desired qualification of nursing services staff which is written. training. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. . reviewed and updated on an ongoing basis. education. Staff recruitment. education. hiring and appointment are based on institutional. hire and appoint nursing services personnel and are uniformly implemented. The licensure. type of services. Measurable Elements 1. patients’ mix. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. selection. 3. Selection. reviewed and updated on an ongoing basis. training and work experiences of nursing personnel are documented and updated. Those responsible for Nursing Services governance consider the organization’s mission. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. 3. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. select. Measurable Elements 1. Standard III: Recruitment. There are legitimate and legitimized processes to recruit. work experience) and other pertinent requirements. staff and skills mix and other factors affecting the projection of staffing needs. level and modality of care. verifying and evaluating the nursing staff credentials. verifying and evaluating the nursing staff credentials (licensure. There is evidence of standardized procedure to gather the credentials of all nursing staff. hiring. selection. 3. Those responsible for Nursing Services governance develop an effective process for gathering. 2. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. Measurable Elements 1. Those responsible for Nursing Services governance develop a staffing plan that identify the number. hiring.The Nursing Services Department has a staffing plan that identify the number. 2. 2. type and desired qualification (education. selection. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment.
There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. Measurable Elements 1. There is a written Job Description for each position classification of Nursing Services personnel which . Measurable Elements 1. Staff placement/assi gnment is based on patient 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. available resources and staff competencies. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. which specifies duties and responsibilities based on established standards of performance.2. 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. 3.
Measurable Elements 1.3.1. 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.specifies: 1.2. Duties and responsibilities 1. Functional relationship 1. Accountability 1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses. 2. There is evidence of staff development programs for all nursing personnel .4.
training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. 3. Safety program to protect the patient. staff and property. b. Orientatio n program for newly hired and promoted staff. c. Career counseling and career advanceme nt/ladder. Resources are available to implement the staff development program such as: .throughout the year which include: a. d. Continuing education. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties.
Audiovisual equipment 3. (e. Medication Room) 18.104.22.168. Those responsible for governance. visitors. . tampering. chemicals. the Nursing Services Department provides a safe.6. Those responsible for governance comply with relevant laws. Educational resources 3.g.4. plan and budget for upgrading or replacing key components based on facility inspection findings.g. staff and visitors aligned with that of the organization’s master plan. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2. radio-active materials and waste. Measurable Elements 1. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. Clinical and clerical staff 3. Safety and Security •There is an existing provision for the identification of patient and their families. destruction or loss. 5. Ther e is a wr itten and up-to-date plan. Space and facilities 3.2.5. Records of staff development program are maintained which include: 5. Effectiveness of the program 5.1. Objectives of the program 5. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use.2. Evaluation of the attendees 5.3. chemotherapeutic agents. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning.1. functional and supportive facility to patients and their families. Program design and content 5.3.1. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. staff and others. Resource speakers 4. For efficient and effective delivery of nursing care and services. Policies and procedures on continuing education staff attendance to staff development programs are evident. Title of the program 5. Measurable Elements 1. List of attendees/participants III. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1. 3. regulations and other requirements that are applicable.5. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment.
•Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. • prevention and control programsinvestigation of spills. preventive maintenance. and that E EThere Documentation and reporting system are are infection surveillance.4. hazardous materials and wastes. electrical failure or interruption and medical gases unavailability. labeling. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing. infectious institutional emergencies. inventory and 1. and recall system. : 1.hazardous gases and vapors.7. 1. Infection Control disposal of hazardous materials E EThere is evidencewaste. epidemics. •A written emergency processes is in place in the event of water interruption or contamination. and medical gases are available 24 hours a day. inventory. 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. seven (7) days a week.6. processes in a continuous storage.3. •Monitoring of utilities is evident for . electrical power. Standard III Staff Education 1.policies. Fire Safety waste). use. Utilities •Potable water. procedures and guidelines on infection control are implemented.and comprehensive manner to all patient care and staff work areas. and disasters. regular inspection. 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.
purposes of planning and improvement. Emergencies •An emergency management plan and processes are evident to likely community/ .5. 1.
E ENursing 2. Security of record •Alternative sources of care and services . Standards 3. to patients and their families. Guidelines. 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. Nursing Personnel E ENursing endorsement in between work shifts 1.E EEducational materials and methods in an understandable format and language 1.Community The Nursing Services Department has established •Patient/nursing care services policies. : : Measurable Elements 1. to operate E medical equipment appropriate to their job Activities description. Circular. Vision. E EPolicies. Patients and Families 1. Mission.3.1. procedures and guidelines on patient clinical record. •Health programs •Process to access care Measurable Elements 1. There are written policies. Other Health Professionals (clinical and non. Core Values demonstrate their role in the aforementioned safety Procedures. procedures. in-patient or out-patient available 1.3.2.clinical staff) VI. programs.2.4. Directives. Clinical record for every patient assessed or •Patient/nursing care services treated. Confidentiality of record 1. There is an evidence that the staff can describe andService Philosophy.1. nursing personnel and other health professionals throughout the organization. There is an evidence of staff training EMemorandum. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs. 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.
Master Staffing Plan 1. Committees. Identification of charges in policy and procedures 2.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 22.214.171.124. 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. Guidelines 1.6. Nursing Services Department 1. Tracking of policy and procedures in circulation (e.7. Measurable Elements .2. Procedures. Staff Development Programs 1. procedure codes and definitions 1. Staffing Pattern 1.Minutes of Meeting. Standards 1.4. 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.7.5. Bed Capacity and Occupancy Rate 1. authorized person) V. title.9. Retention of obsolete policies and procedures 2.3. 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. Control that only current policy and procedures are implemented 2. Data Integrity •Protection from tampering 1.4.10. date of issue.1. Measurable Elements 1.3. References originating outside the organization 126.96.36.199.5. Organization and Nursing Services Department Policies.6.• Protection from loss and destruction and unauthorized access and use 1.Review and approval of all policies and procedures before implementation 2. symbols.2.1.g. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. Use and monitoring of standardized abbreviations.Budget Plan 1. Nursing and the Organization 1. Census of Patients and Diseases 1. Process and frequency of review and continued approval of policies and procedures 2.
There is a clinical monitoring that exists but is not limited on the following: 1. Nursing documentation 1. body fluids and waste segregation/disposal) 1.8. Surgical safety (sterilization/disinfection) 1. Clinical research 1.9. guidelines. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.4. surveillance.1. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. Standard II Quality Programs : and other relevant evidence – based information. Intravenous fluids 1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning.g. clinical standards. There is a training program for staff consistent with their role in quality improvement and patient safety program.3. Measurable Elements 1. Medication error 1. scientific literature.2. clinical pathway) 2.1. 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.6. 3. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. 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.5. analyzed and transformed to useful information. implemented and monitored for consistent use and effectiveness. 3 . Blood and blood products 1. 2. 6. (e. There is an established reporting system on the quality and safety programs to governance. 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. . Measurable Elements 1. hand hygiene and barrier technique. 4. Prevention and control measures aligned with International Patient Safety Goals. high risk and problemprone processes. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. processes and results and data are aggregated. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. 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. Total parenteral nutrition 1. monitoring. Standard III Quality Monitoring. reporting (needle stick injury.7. Infection control. 5.
It includes the role of management to produce and control the use of data and information in work activities. Communication Management – is the creation. level of medical. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. Discharge Summary – is a section of patient record that summarizes the reasons for admittance.g. The process determines if an individual can provide patient care services in or for a health care organization. the procedures performed. use. information resources management. This applies within an organization or across multiple organizations. or spiritual and social care or service. scope and severity of the problems.hat exists but is not limited on the following: iagnoses d complaints. or nursing care. tested and implemented. verifying. and assessing the qualifications of a health care practitioner like the nursing personnel. elements of care. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. the significant findings. ulation and those in governance and actions taken. Credentialing – is the process of obtaining. the treatment rendered. and information services. that includes actions for improvement or changes are planned. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. the patient’s condition on discharge. psychological. if any supplies essential to most patient needs (e. demonstrate that the improvements are effective and sustained. information technology. sharing and disposal of data or information for effective and efficient operation of organization activities. and other specific .
laboratories and long term organizations. nurse. Informed Consent – is an agreement or permission accompanied by full information on the nature. Other names for this group include “board. and his/her life expectancy is estimated to be within days or months. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment.” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. medications). dentist.” 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. It is also known as a “health care institution.” and “governing body. home care organizations.” board of governors. group or agency that have ultimate authority and responsibility for establishing policy. This includes ambulatory care centers. and alternatives of a medical procedure or treatment before the . Health care professionals are often licensed by a government agency or certified by a professional organization. and providing for organization management and planning. behavioral/mental health institutions. over time. maintaining quality of care. or process. risks. systems. hospitals.” “board of commissioners.” “board of trustees. This includes a physician. follow –up. Indicator – is a measure of the performance of functions. Governance – refers to the individual(s).instructions given to the patient or family (for example.
Patient Record/Clinical Record – is a written account of a variety of patient health information. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. usually provided in the workplace. and documents the individual’s progress in meeting specified goals and objectives. progress notes and discharge summary. physicians and other health care professionals involved in the care of patients. lists the strategy to meet those needs. and rehabilitation. Qualification is determined by the following: education. care. clinical paths or a combination of these. It is based on data gathered during patient assessment. Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. experience. treatment. . Management. Coulter M (2004). This record is created by nurses. The plan of care may include prevention. S. training. outlines the criteria for ending intervention. th Edition. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. The format of the plan in some organizations may be guided by specific policies and procedures. registration. applicable licensure. competence. physician or other health care professional begins the procedure or treatment. protocols. practice guidelines. 7 Pearson Education South Asia PTE LTD. In-Service Education – is an organized education. habilitation. or certification. treatment details. Plan of Care – is a plan that identifies the patient’s care needs. documents treatment goals and objectives. law or regulation. such as assessment findings.Robbins.
New York Republic Act 9173 or The Philippine Nursing Act of 1991. . Inc. Hollenback. treatment. Association of Nursing Service Administrators of the nursing practitioners are accountable. Metro Manila ctures. Human Resources for Hospitals. Fundamental of Human Resource Management. or process that must be in place for escribe the responsibilities for which t to receive. Philippines. and service. 1 st Edition Joint Commission International (2008). Republic of the Philippines. Inc. Credentialing. (1999). Accreditation Standards for Hospitals. and Philippine Nurses Association. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. Edition Printed in USA 54321 Noe. Edition Printed in USA 54321 Joint Commission International (2004). Inc. 3 rd Edition Printed in USA 54321 Joint Commission International (2004). Inc. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). Gerhart. McGraw-Hill Co. The Administration of Hospital Nursing Services in Philippine Department of Health. and other persons. Wright (2004). REFERENCES an organization to provide safe and high-quality care. including health care providers.opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge.
Guide to Nursing Management and Leadership. 5 Edition. th Editi Rowland H & Rowland B (1980). S. Management. 7 th Edition Weber. Coulter M (2004).Robbins.M (2004). J (2006). 7 Pearson Education South Asia PTE LTD. Lippincott Williams & Wilkins th . Aspen Publication Tomey A. Nursing Administration Handbook. Nurse’s Handbook of Health Assessment.
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