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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.
There are seven (7) criteria that guide the nurses regarding the importance of access to care.also is the medication management and the family rights. These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. III. IV. 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 five (5) standards identified: I. direction. Standards on Human Resource Management . There are seven (7) criteria included. This chapter recommends the .needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. These focus also on planning. professional standards and institutional requirements. organization and controlling functions of the nursing service administration and their relationship with other services. It The second part is the Administration and 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 . need for organizational structure which will delineate responsibility. Standards on Nursing Documentation . which include documentation of significant data both structure. V. This concerns managing the nursing services in the hospital. There are two identified criteria under this component. accountability and authority of nursing administration. and clinical based on applicable laws and regulations. II.
This standard contains three (3) criteria and covers environmental safety IV. It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective. Standards on Facility Management and Environmental Safety . administration record and communication of information.also includes staffing modalities depending on the type of services. This standard has three (3) criteria which address the need to institutionalize V. Three (3) criteria are identified focusing on the patient’s record. Standards on Quality Improvement . III. . Standards on Communicati on Management .
Each standard and criteria has identified measurable elements intended to provide clarity to the standards and to help organizations develop their own policies and procedures according to the standards.continuous quality and performance improvement. .
g. 2.1. Those responsible for direct nursing care prioritize patients’ needs based on assessment results. 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. plan of care. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following: 1.0. 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. Pain is . Psychological •Knowledge level •Language spoken •Barriers to learning 1. individual needs or (e. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me. 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. Measurable Elements 1.
5. extended. Nutritional – Metabolic Pattern 2. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2.3. Activity – Exercise Pattern 2. Nutritional status. Economic factor •Financial barrier 1.9. Social •Cultura l concerns 1. Elimination Pattern 2.5. address. Sexuality – Reproductive Pattern 2.1. needs and risks 1.6.7. Role – Relationship Pattern 2.7. There is an established screening criteria according to patients’ functional capacity and needs like: 2.6. Cognitive Pattern . Sensory – Perceptual Pattern 2.11. Spiritual •Religion 1.8. telephone number. Vital signs 1. Sleep – Rest Pattern 2. Self – Concept Pattern 2.2.3. relationship) 2.• Sensory assessment 1.Discharge plan •Place: home.Preference and idiosyncrasies 126.96.36.199.10. Pain assessment 1. skilled care facility •Individual who will accompany the patient home (name.10.Coping – Stress Tolerance Pattern 1.4.
2. Assistance with activities of daily living 5. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. 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. There are existing policies and procedures on care process developed by those responsible for governance which include . 5. Lack of mobility 5. Continuing medical and nursing needs 5. Measurable Elements 1. 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. but are not limited on the following: 4.2.11. Other pertinent data are collected using the appropriate assessment.5.3. technique and instruments.Value – Belief Pattern 3.Referral for continuity of care as necessary II.4.1. Age 5.
6. Care of patient in pain 1.suppressed patients 1. Care of patient in restraint 1. religious and other beliefs of patients.7. 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. 2.14. Patient participate in planning of care taking into consideration the cultural.4.10. ventilatory equipment) Care of patient on dialysis (hemodialysis.1. Care of patient receiving blood and blood components 1. 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. •Disabled 1. Measurable Elements 1. 6. Care of patient on nutritional therapy 1.3.5. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. The care plan ensures that priorities of care are established.11.9.8. The care plan is updated as appropriate based on the reassessment made. 1. alleviation of suffering and restoration of health. 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.g. Care of patient with communicable diseases 1.13. 4.1. 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: . 1. 5. Care of perioperative patient 1. 1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2.1. There is an evidence that family and significant others are involved in the planning process. Care of comatose patient 1. 3. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e. The care plan is documented in the individual patient’s record to promote continuity of care. Measurable Elements 1.12. Care of patient on chemotherapy 1.15.2. prevention of illness. Care of immune .
2. evaluate and manage patients in pain. Measurable Elements 1. Ten (10) Golden Rules in Drug Administration 1. 2.g. monitor.6.based practice 1. 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. monitor. There is evidence that patients receive care according to pain management guidelines. . Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. evaluate and manage patients in pain. There is an existing pain management guideline for nurses to appropriately assess.1. Standard IV: Evaluation of Care Measurable Elements 1. Scope of Nursing Practice as provided by law and all relevant legislations (e. 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.1. There is an evidence that patient’s responses to interventions are documented. Patient Bill of Rights 2.3.4. Evidence .5. 3. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. 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. The revision in care plan if any is reflected in the patient record. 4.2.Code of Ethics for Nurses 1. 1.
Monitoring and Storage 1. Emergency Drugs 188.8.131.52. Carrying out physician’s medication order 1. 4. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment. religion and cultural preferences and practices is evident.3. Administering (10 Golden Rules in Drug Administration) 1.1. Personal hygiene is rendered based on patient’s need. preventive. Living will if any. Advance directives Do Not Resuscitate.1. 1.9. 1. Labeling 1.4. Transcribing and ordering 1.5. intervention and evaluation. 1.3. 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. and palliative treatment of patients’ diseases and for safe nursing practice. Endorsing (especially high valuable drugs) 1. procedures and guidelines on medication management which include but are not limited on the following: 1. are monitored and recorded. 2.10. curative.3. Preparing 1. 2. The patient’s right of self-determination and choices are respected and accommodated. rules and regulations. . 1. Documenting 1.11. Measurable Elements 1. Patient and family choices to donate organs and other tissue are supported through provision of relevant information.7. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. Waiver.Regulated Drugs 1. 2.2. There are written policies. Pastoral services are provided based on the spiritual beliefs of the patient and family.Medication Recall System (Expired or Outdated Drugs) 1. Pain assessment.2.4. Respect for patient’s values. There are existing education and training programs for nurses on pain management. psychological. are respected. Processes to communicate with and evaluate patients and families about pain are evident. Assessment.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1. In accordance to statutory laws.12. Standard VI: Medication Management The Nursing Services Department has established policies. procedures and guidelines on medication management for symptomatic.8.
spiritual and cultural concerns.g. processes and guidelines that respect and support patient and family rights. treatment. 4.1. Patient’s and family’s beliefs and values 1.2. Patient’s and family’s literacy 1. 3. procedure.Respect for patient’s need for privacy (e. 2. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies.4. emotional. children and elderly) 1. There is evidence that nurses are knowledgeable and supportive of patient and family rights. Protection of patient from physical assault (e.7.4. outcome of care. Measurable Elements 1. Measurable Elements 1. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. 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. Interventions address patient and family’s psychosocial.184.108.40.206. vulnerable patients are infants. 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. There are written policies. 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. clinical interview. transport) 1. A place is designated for the patient’s family to stay.2. during treatment. III. physical examination. 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. The patient and family are involved in care management and decision. Protection of patient’s possessions from theft or loss 1.3. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. Respect for patient’s personal values and beliefs 1. Patient’s and family’s educational level . 1.g.6.2. Respect the confidentiality of patient health information 1.
Patient’s physical and cognitive limitation 1.1 to 4. 3.4. Education resources are available and organized in an efficient and effective manner. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1. Patient’s and family’s motivations and emotional barriers 1. 6.5. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. Safe and effective use of medications and their side effects 4.6. 2. adequate time and communication skills to do so. Measurable Elements 1. Pain management 4.1. When appropriate. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. Rehabilitation techniques 4.3. Process for admitting patient or registering out patient 1. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1. Holding area for patient on observation 1. Treatment and diagnostic procedures IV.5.4. The appropriate structure.5) are available. Clinical services available 1.7. There is an evidence that nurses who provide education have the subject knowledge. Criteria for admitting patient or registering out patient 1.1.4. Safe and effective use of medical equipment 4. methods and mechanism for education is afforded.1. 4.2. 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. it is evident that the patient and family are educated on topics considered high risk to patients: 4. Preventing interactions between prescribed medications and other medications (over the counter) and food 4. Patient’s and family’s language 220.127.116.11. Measurable Elements 1. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients . 5.5.6.
There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs.1. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. cultural. curative. 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. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training.4. There is an evidence that patients with immediate needs/care are assessed.3. 2. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. 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. 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 staff who responded to emergency patients underwent the necessary training. Measurable Elements 1. Limit or overcome barriers such as language.2.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse.Proposed plan of care 2. . physical. 4. Expected outcome of care 2. Measurable Elements 1.5. It is evident that criteria is physiologic-based and developed by appropriate individuals. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. Sufficient information to make knowledgeable decision and 2.Expected cost of care 2. 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. 3. the Nursing Services Department has established policies and processes on patient continuity of care aligned with those of the organization and coordinated among other health professionals. Measurable Elements 1. Standard V: Continuity of Care In diverse health care setting. 2. curative. 2. There is an evidence that nurse screening assessment focuses on preventive.
The patient’s discharge summary is prepared by qualified individuals recognized by the organization. out on pass. referral and follow-up congruent with those of the organization. out on pass. Significant physical and other findings 6. there is a qualified individual. referral and follow-up congruent with those of the organization. During all phases of care.5.4. Continuity of care and coordination of services are evident throughout all phases of care.8.5. Other health care settings 2. Referral for support services to either health care providers.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6. Standard VII: Transfer of Patient The Nursing Services Department has established policies. There is a process on out on pass patients for a defined period of time. 2. Significant diagnosis and co-morbidities 6. 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. Out patient care programs 1. 5. Nursing ward services to diagnostic services 1. Condition of patient at the time of discharge 6. Out on Pass. 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: 18.104.22.168. 6. Reason for admission 6. Standard VI: Discharge.2.6. Medications and treatments 6. and health professionals in the community. Between nursing units or clinical departments 22.214.171.124. 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. Measurable Elements 1.7. 3. There are written policies. Diagnostic and therapeutic procedures performed 6. identified as responsible for patient care and documented in the patient record. There is a referral system of patients for transfer to other organization.9. 4. health organizations or agency. .1. Medications to be taken at home 6.Measurable Elements 1. There are criteria that determine patients readiness to be discharged. procedures and guidelines regarding the transfer of patient within and outside of the organization.Nursing ward services to surgical and non surgical services 1. procedures and guidelines on patient’s discharge. Emergency services to nursing ward admission 1.1.
Transfer of responsibility to another health provider or health care setting is evident. transferring hospital. Patient’s transfer is documented.Measurable Elements 1. stretcher 1. Patient’s addressograph – name. 2. Responsible health care provider during the patient’s transfer is identified.5. gender. 2.1.6. 2.5.3. Mode of admission/transport/discharge 1.9. Registration number and or Admission number 1. Measurable Elements .2. Advance directive 1. Formal and informal arrangements are apparent.8.4. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1.1. procedure and guidelines on transfer of patient within and outside of the organization.4.2.6. Safe and quality medical transport services within and outside of the organization are provided. Religion 1. Language spoken 1. interventions (medical and nursing) and continuous care rendered are written. Admitted from: home. care facility 1. Transfer is based on the patient’s needs for continuity of care.4. Situation when transfer is not possible is stated. 2.1. 2.7. Attending physician and referring physician.4. civil status 1. Date and time of admission and discharge 1. Health Care Insurance Standard II: Clinical Data The nurse documents essential clinical data of each patient accurately and completely based on individualized nursing care plan from admission to discharge in health care facility. age. 2. Summary of patient’s clinical condition. 2. V.The guidelines and procedures include but are not limited on the following: 2.There is a written policy.3. wheelchair.2. 2. if any 1.7. Admitted via: ambulatory.8.
Health history Standard II: Governance Responsibility and Accountability . Physical examination (head-to-toe) 1. professional standards and institutional requirements. Measurable Elements 1.2. 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: 1.1.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. There is relevant/essential. There is an accurate and complete documentation of patients’ structural data in all nursing and 1.
The Nursing Services governance structure is described in written documents with the approval of proper authority. The Nursing Services governance structure and processes support professional communication.1. Measurable Elements 1. 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. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.4. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I. 4. . Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. 2. spiritual and economic evaluation 1. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.10.Pharmacological management 1.7.Health teachings – patient and family 1.3. 3.6.Nursing interventions 1.5. Psychological. clinical planning and services and policy development. social.Actual and potential health problems and needs 1.9.Diagnostic and therapeutic interventions 1.8. authority.
Measurable Elements 1. 4. primarily sets its direction by formulating its vision. reliable. There is a written document that describes how the performances of the governing entity are appraised by specific criteria. Standard II: Governance Responsibility and Accountability . core values and quality objectives congruent with that of the institution and the Nursing profession. Measurable Elements 1. core values and quality objectives congruent with that of the institution and the Nursing profession. 2. mission. mission. mission. job description and other similar documents. measurable. 3. The governance responsibility and accountability are described in organization’s by-laws. The vision. 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. attainable. managers. 2. philosophy. Those responsible for the Nursing Services Department governance. philosophy and core values are written ( specific. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. Standard III: Direction-Setting The Nursing Services Department has an established vision.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. philosophy.
Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. resources required and contingencies. nursing manpower and unit operation of responsibility areas. 3. 2. interpreted and operationalized. action plan/activities. Those responsible for governance have established current financial plans and allocation of resources . timeframe. ethical and recorded ). 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. reviewed. widely disseminated. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan.time bound. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. Measurable Elements 1. Measurable Elements 1. Those in the managerial and clinical levels translate the overall Nursing Services Department’ strategic and management plans into action which include: the management of patient care. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. updated.
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. 3. 3. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. 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. 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 governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. Each Nursing Unit has an individual budget plan periodically monitored for variances. The medical supplies. 2.2. 4. regulations and standards. rules and regulations. 2. . Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Measurable Elements 1. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. 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. Measurable Elements 1. professional and interprofessional relationships and other related endeavors. and conforms with the applicable statutory laws. 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.
1. There are Resource Management presence of Standard I: evidences Administrator of that the Nursing Services Nursing Service The Nursing Administra Services Department tor is is administered by a qualified qualified nursing to the administrator position pertinent to based on licensure. Be a member of good standing of the accredited professional organization of nurses. Nursing Measurable Elements Service Admini strators : . Standards on Human 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. n such as: fully responsible and 1. RA 9173 appropriate education. II. and 1.4.administration courses at the graduate level.
A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. 1.1. Be a regist ered nur se in the Philippi nes. with a least nine ( 9) unit s in man age ment and .3.1. Poss ess a degr ee of bach elor of Scien ce in Nursi ng. 1. 1.1. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n.2.
1.1.).2. 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 master’s degree major in nursing.1.1).1.3.4. a n d 1. 1. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1.A person occupying the position of chief nurse of director of nursing service shall. possess: 1.1.2. in addition to the foregoing qualificatio ns. and (1. . That for chief nurses in . (1.1. That for primary hospitals .2.1.3) of the above.
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. That for chief nurses in military hospitals.the public health agencies. 2.5. priority shall be given to those who have finished a master’s degree in nursing and the completio n of the General Staff Course (GSC). Standard II Staffing Plan : . those who have a master’s degree in public health/com munity health nursing shall be given priority. 1.
3. patients’ mix. Selection. 2. 3. Measurable Elements 1. 3. Measurable Elements 1. training. Those responsible for Nursing Services governance consider the organization’s mission. education. 2. The licensure. selection. type of services. education. selection. work experience) and other pertinent requirements. hiring and appointment are based on institutional. hiring. verifying and evaluating the nursing staff credentials. level and modality of care. patients’ needs and applicant qualification. Those responsible for Nursing Services governance develop 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. Standard III: Recruitment. select. reviewed and updated on an ongoing basis. type and desired qualification of nursing services staff which is written. Those responsible for Nursing Services governance develop a staffing plan that identify the number. staff and skills mix and other factors affecting the projection of staffing needs. There are legitimate and legitimized processes to recruit. . There is evidence of standardized procedure to gather the credentials of all nursing staff. skills and experience) of Nursing Services staff. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. type and desired qualification (education.The Nursing Services Department has a staffing plan that identify the number. Staff recruitment. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. hire and appoint nursing services personnel and are uniformly implemented. 2. Measurable Elements 1. verifying and evaluating the nursing staff credentials (licensure. reviewed and updated on an ongoing basis. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. hiring. 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. training and work experiences of nursing personnel are documented and updated. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. selection.
There is a written Job Description for each position classification of Nursing Services personnel which . Measurable Elements 1.2. 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. which specifies duties and responsibilities based on established standards of performance. 3. Staff placement/assi gnment is based on patient needs. Measurable Elements 1. 2. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. 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. available resources and staff competencies.
Functional relationship 1. Duties and responsibilities 1. There is evidence of staff development programs for all nursing personnel . Accountability 1.1. Measurable Elements 1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.specifies: 1. 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.2.4. 2.3.
staff and property. 3.throughout the year which include: a. Career counseling and career advanceme nt/ladder. c. Orientatio n program for newly hired and promoted staff. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties. b. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. d. Safety program to protect the patient. Resources are available to implement the staff development program such as: . Continuing education.
1. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning. Space and facilities 3.5. staff and others. Ther e is a wr itten and up-to-date plan. tampering. Objectives of the program 5. chemotherapeutic agents. Audiovisual equipment 3. functional and supportive facility to patients and their families. destruction or loss.1. Clinical and clerical staff 3. Those responsible for governance comply with relevant laws.4.1.3. Program design and content 5. Records of staff development program are maintained which include: 5. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment.3. regulations and other requirements that are applicable. List of attendees/participants III. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2. Measurable Elements 1. . Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 126.96.36.199. Medication Room) 1. the Nursing Services Department provides a safe.g. chemicals. 3. radio-active materials and waste.6. staff and visitors aligned with that of the organization’s master plan. Educational resources 3. Evaluation of the attendees 5. Safety and Security •There is an existing provision for the identification of patient and their families. 5. plan and budget for upgrading or replacing key components based on facility inspection findings. Title of the program 5. Effectiveness of the program 5.2.2. Resource speakers 4. Measurable Elements 1. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use. Policies and procedures on continuing education staff attendance to staff development programs are evident. Those responsible for governance. For efficient and effective delivery of nursing care and services.g. (e. visitors.3.
•Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement.policies.4. regular inspection. inventory.6. 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. hazardous materials and wastes. and disasters. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing. electrical failure or interruption and medical gases unavailability. epidemics.7. procedures and guidelines on infection control are implemented. labeling. 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.and comprehensive manner to all patient care and staff work areas. preventive maintenance. and medical gases are available 24 hours a day. and recall system. processes in a continuous storage. 1. use. Standard III Staff Education 1.hazardous gases and vapors. seven (7) days a week. infectious institutional emergencies. Infection Control disposal of hazardous materials E EThere is evidencewaste. inventory and 1. electrical power. • prevention and control programsinvestigation of spills. Fire Safety waste). •Monitoring of utilities is evident for . : 1. and that E EThere Documentation and reporting system are are infection surveillance.3. Utilities •Potable water. •A written emergency processes is in place in the event of water interruption or contamination.
Emergencies •An emergency management plan and processes are evident to likely community/ .5. 1.purposes of planning and improvement.
Other Health Professionals (clinical and non.clinical staff) VI. There are written policies.Community The Nursing Services Department has established •Patient/nursing care services policies. Standards 3. E EPolicies.3. Patients and Families 1. Clinical record for every patient assessed or •Patient/nursing care services treated. in-patient or out-patient available 1. Nursing Personnel E ENursing endorsement in between work shifts 1. Circular. Standards on Communication Management E EPatient care and response to care (referral) E E clinical data (diagnostic Standard I Communication of InformationPatient examinations and therapeutic procedures) E ECircular The Nursing Services Department has efficient and Standard II Patient Clinical Record effective system of communication with the community. Directives. procedures. nursing personnel and other health professionals throughout the organization. 1. There is an evidence that the staff can describe andService Philosophy. 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. 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. to patients and their families.1. •Health programs •Process to access care Measurable Elements 1. There is an evidence of staff training EMemorandum. Confidentiality of record 1. programs.3.2. Mission.2.E EEducational materials and methods in an understandable format and language 1. Core Values demonstrate their role in the aforementioned safety Procedures. to operate E medical equipment appropriate to their job Activities description. Vision. Security of record •Alternative sources of care and services . Guidelines.4. : : Measurable Elements 1. E ENursing 2. procedures and guidelines on patient clinical record.1.
There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. Nursing Services Department 1.2.Review and approval of all policies and procedures before implementation 2. Organization and Nursing Services Department Policies.5. Guidelines 1.11.9. References originating outside the organization 2. Standards 188.8.131.52.1. Data Integrity •Protection from tampering 1.10. Retention of obsolete policies and procedures 2.6.3. title. Bed Capacity and Occupancy Rate 1.4. Process and frequency of review and continued approval of policies and procedures 2. symbols. Tracking of policy and procedures in circulation (e.3.6.Budget Plan 1.1. Standards on Quality Improvement Standard I Leadership and Staff Education : The Nursing Services Department has continuous quality improvement on patient and staff safety programs through monitoring and analyzing variation of data and undesirable trends of events. 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. Control that only current policy and procedures are implemented 2. Procedures. procedure codes and definitions 1.6. Staffing Pattern 1. Nursing and the Organization 1. Identification of charges in policy and procedures 2.Quality Improvement Program and other Projects 1.Master Staffing Plan 1.5.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2.• Protection from loss and destruction and unauthorized access and use 1. Staff Development Programs 1. Measurable Elements .Minutes of Meeting. authorized person) V.8. Use and monitoring of standardized abbreviations. 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. Measurable Elements 1. Census of Patients and Diseases 1. Committees.7.4.g.4.12. date of issue.
g. There is a clinical monitoring that exists but is not limited on the following: 1. analyzed and transformed to useful information. 3. processes and results and data are aggregated. hand hygiene and barrier technique.4. surveillance.1. implemented and monitored for consistent use and effectiveness. Nursing documentation 1.5.2. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. 2. 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. monitoring. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment. body fluids and waste segregation/disposal) 1. . 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.9. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. scientific literature. Total parenteral nutrition 1. clinical pathway) 2. Clinical research 1. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. guidelines. There is an established reporting system on the quality and safety programs to governance. Medication error 1. Measurable Elements 1.3. 6. There is a training program for staff consistent with their role in quality improvement and patient safety program. Infection control. Prevention and control measures aligned with International Patient Safety Goals. Intravenous fluids 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. Blood and blood products 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. clinical standards. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. Standard II Quality Programs : and other relevant evidence – based information. Medication safety. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. 3 .7.8. 5. high risk and problemprone processes. 4. Surgical safety (sterilization/disinfection) 1.6. Measurable Elements 1.1. (e. Standard III Quality Monitoring. reporting (needle stick injury.
hat exists but is not limited on the following: iagnoses d complaints. ulation and those in governance and actions taken. demonstrate that the improvements are effective and sustained. the significant findings. and other specific . that includes actions for improvement or changes are planned. This applies within an organization or across multiple organizations. the procedures performed. level of medical. information technology. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. or spiritual and social care or service. scope and severity of the problems. the patient’s condition on discharge. and information services. use. tested and implemented. information resources management. and assessing the qualifications of a health care practitioner like the nursing personnel. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. The process determines if an individual can provide patient care services in or for a health care organization. psychological. verifying. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. the treatment rendered. elements of care. or nursing care. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. Credentialing – is the process of obtaining.g. if any supplies essential to most patient needs (e. sharing and disposal of data or information for effective and efficient operation of organization activities. It includes the role of management to produce and control the use of data and information in work activities. Communication Management – is the creation.
maintaining quality of care. behavioral/mental health institutions. or allied health professionals. risks. nurse. group or agency that have ultimate authority and responsibility for establishing policy.” and “governing body. 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. laboratories and long term organizations. follow –up.” board of governors. and alternatives of a medical procedure or treatment before the .” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment.” “board of trustees. Other names for this group include “board.” “board of commissioners. dentist. This includes ambulatory care centers. and his/her life expectancy is estimated to be within days or months. This includes a physician. It is also known as a “health care institution. Indicator – is a measure of the performance of functions. systems. medications). over time. or process. hospitals.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. home care organizations. Governance – refers to the individual(s). and providing for organization management and planning.instructions given to the patient or family (for example.
clinical paths or a combination of these. . protocols. training. The plan of care may include prevention. 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. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. competence. outlines the criteria for ending intervention. care. Patient Record/Clinical Record – is a written account of a variety of patient health information. and rehabilitation. treatment. treatment details. applicable licensure. usually provided in the workplace. or certification. habilitation. Management. 7 Pearson Education South Asia PTE LTD. documents treatment goals and objectives.Robbins. experience. Qualification is determined by the following: education. This record is created by nurses. In-Service Education – is an organized education. lists the strategy to meet those needs. law or regulation. It is based on data gathered during patient assessment. and documents the individual’s progress in meeting specified goals and objectives. registration. 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. progress notes and discharge summary. physicians and other health care professionals involved in the care of patients. Coulter M (2004). such as assessment findings. S. physician or other health care professional begins the procedure or treatment. practice guidelines. th Edition.
. Edition Printed in USA 54321 Noe. Wright (2004). 1 st Edition Joint Commission International (2008). Association of Nursing Service Administrators of the nursing practitioners are accountable. Hollenback. Credentialing. Human Resources for Hospitals. Inc. and Philippine Nurses Association. Inc. Accreditation Standards for Hospitals. Metro Manila ctures. REFERENCES an organization to provide safe and high-quality care. (1999). Republic of the Philippines. treatment. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. Fundamental of Human Resource Management. and other persons. Gerhart. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). Inc. and service. including health care providers. Inc.opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge. New York Republic Act 9173 or The Philippine Nursing Act of 1991. Philippines. Edition Printed in USA 54321 Joint Commission International (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). The Administration of Hospital Nursing Services in Philippine Department of Health. McGraw-Hill Co.
Guide to Nursing Management and Leadership. Nursing Administration Handbook. Coulter M (2004). 5 Edition. Aspen Publication Tomey A. S. 7 Pearson Education South Asia PTE LTD. 7 th Edition Weber. th Editi Rowland H & Rowland B (1980).M (2004).Robbins. Nurse’s Handbook of Health Assessment. J (2006). Lippincott Williams & Wilkins th . Management.
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