STANDARDS OF NURSING SERVICES

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.

FOREWORD
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

.Standards

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

The
Standard III. Standard IV. Standard V. Standard VI. Standard V.

first

part

is

Clinical

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 Programs
Quality Monitoring, Analysis and Implementation

Staff Development

I.

. Standard I. Standard II. Standard III.

Safety

. Standard I. Standard II. Standard III.

.Standards on Communication Management
II.

Standard I. Standard II. Standard III.

also is the medication management and the family rights. 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. These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. IV. There are seven (7) criteria that guide the nurses regarding the importance of access to care. .

Standards on Governance and Direction . This part contains five (5) criteria which help the nursing administrators in placing the right person to do the right job through identification of the job requirements and qualifications. V.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. which include documentation of significant data both structure. These focus also on planning. There are five (5) standards identified: I. There are two identified criteria under this component. Standards on Nursing Documentation . direction. organization and controlling functions of the nursing service administration and their relationship with other services. This concerns managing the nursing services in the hospital. and clinical based on applicable laws and regulations. Standards on Human Resource Management . professional standards and institutional requirements. There are seven (7) criteria included. It The second part is the Administration and Management. accountability and authority of nursing administration. This chapter recommends the . II. need for organizational structure which will delineate responsibility.

administration record and communication of information. Three (3) criteria are identified focusing on the patient’s record. . III. Standards on Facility Management and Environmental Safety . This standard contains three (3) criteria and covers environmental safety IV.also includes staffing modalities depending on the type of services. Standards on Quality Improvement . Standards on Communicati on Management . It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective. This standard has three (3) criteria which address the need to institutionalize V.

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. .

1. Those responsible for direct nursing care prioritize patients’ needs based on assessment results.g.0. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me. Measurable Elements 1. individual needs or (e. 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. 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.2. Pain is .1. plan of care. erval appropriate to patient’s condition. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. Psychological •Knowledge level •Language spoken •Barriers to learning 1. 2. 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.

9. Nutritional status. Sexuality – Reproductive Pattern 2. There is an established screening criteria according to patients’ functional capacity and needs like: 2.10. Self – Concept Pattern 2. telephone number.5. address. relationship) 2.Discharge plan •Place: home.8. Cognitive Pattern . Role – Relationship Pattern 2. Social •Cultura l concerns 1. Nutritional – Metabolic Pattern 2.4. skilled care facility •Individual who will accompany the patient home (name. Sensory – Perceptual Pattern 2.4.7.3.Coping – Stress Tolerance Pattern 1. Spiritual •Religion 1. Economic factor •Financial barrier 1. Pain assessment 1.7.6.3.10. needs and risks 1.8. Sleep – Rest Pattern 2. Activity – Exercise Pattern 2. Elimination Pattern 2.11.1.Preference and idiosyncrasies 1.9.• Sensory assessment 1.2.6. Vital signs 1. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2. extended.5.

technique and instruments. Measurable Elements 1.Referral for continuity of care as necessary II.2. 5.5.4.11. There are existing policies and procedures on care process developed by those responsible for governance which include .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. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. Other pertinent data are collected using the appropriate assessment. Continuing medical and nursing needs 5. Assistance with activities of daily living 5.Value – Belief Pattern 3.2. 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. but are not limited on the following: 4.3. Age 5. Lack of mobility 5.

Care of patient in pain 1. 1. The care plan is documented in the individual patient’s record to promote continuity of care.g. Care of comatose patient 1. 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.1. alleviation of suffering and restoration of health. prevention of illness. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e.6. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. Care of patient in restraint 1. Care of patient on nutritional therapy 1. 4.8.3. 2.1. 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: . ventilatory equipment) Care of patient on dialysis (hemodialysis. 3. Care of patient receiving medications with narrow margin of safety 1.5.2. Care of immune . •Disabled 1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2. religious and other beliefs of patients.suppressed patients 1.10. Care of perioperative patient 1.9. Care of patient receiving blood and blood components 1.11.1.12. Measurable Elements 1. 6. Care of patient on chemotherapy 1. There is a written care plan on every patient cared of by the nurse based on patient’s initial assessment data within the 1 st 24 hours of assessment or earlier. There is an evidence that family and significant others are involved in the planning process.7. 1. The care plan is updated as appropriate based on the reassessment made. Care of patient with communicable diseases 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.14. The care plan ensures that priorities of care are established.4. 1.13.15. Measurable Elements 1. Patient participate in planning of care taking into consideration the cultural. 5.

monitor. There is evidence that patients receive care according to pain management guidelines.6. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. 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. 1. Ten (10) Golden Rules in Drug Administration 1.g. 2. 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. Patient Bill of Rights 2. 4. Evidence . evaluate and manage patients in pain. Standard IV: Evaluation of Care Measurable Elements 1. Scope of Nursing Practice as provided by law and all relevant legislations (e. Measurable Elements 1.Code of Ethics for Nurses 1. 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. evaluate and manage patients in pain. 2.based practice 1. There is an evidence that patient’s responses to interventions are documented. 3. The revision in care plan if any is reflected in the patient record. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. monitor. There is an existing pain management guideline for nurses to appropriately assess. .4.2.1.3.5. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations.

2. Personal hygiene is rendered based on patient’s need. Transcribing and ordering 1. religion and cultural preferences and practices is evident. 1. procedures and guidelines on medication management for symptomatic. Pain assessment.4.11. Waiver. There are existing education and training programs for nurses on pain management. The patient’s right of self-determination and choices are respected and accommodated. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. Respect for patient’s values.6. Labeling 1.7.1. intervention and evaluation. 1. 4.2. Carrying out physician’s medication order 1. Measurable Elements 1.12. .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.3. are monitored and recorded. preventive. 2.Regulated Drugs 1. rules and regulations. are respected. Administering (10 Golden Rules in Drug Administration) 1. In accordance to statutory laws. Assessment. There are written policies.1. 1.5. 2.9. psychological.2. Standard VI: Medication Management The Nursing Services Department has established policies.Medication Recall System (Expired or Outdated Drugs) 1. 1. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment.3.4. procedures and guidelines on medication management which include but are not limited on the following: 1. Living will if any. and palliative treatment of patients’ diseases and for safe nursing practice.10. 2. Monitoring and Storage 1. Preparing 1.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1. curative. Endorsing (especially high valuable drugs) 1. Advance directives Do Not Resuscitate.8. Documenting 1. Pastoral services are provided based on the spiritual beliefs of the patient and family. Emergency Drugs 1.3. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. Processes to communicate with and evaluate patients and families about pain are evident.

g. There is evidence that nurses are knowledgeable and supportive of patient and family rights. 3. 4. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies.3.3. clinical interview. The patient and family are involved in care management and decision.1. emotional.1. Protection of patient’s possessions from theft or loss 1. Patient’s and family’s educational level .6. vulnerable patients are infants. 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. Patient’s and family’s literacy 1. There are written policies. Interventions address patient and family’s psychosocial.5.2. A place is designated for the patient’s family to stay.7. Measurable Elements 1. Measurable Elements 1. physical examination.g.2.3. Respect the confidentiality of patient health information 1.2. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. spiritual and cultural concerns. transport) 1. children and elderly) 1. 1. 2. treatment. 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.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. Protection of patient from physical assault (e. Patient’s and family’s beliefs and values 1.Respect for patient’s need for privacy (e.4. during treatment. outcome of care. III. Respect for patient’s personal values and beliefs 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.4. 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. processes and guidelines that respect and support patient and family rights.

Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients . 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 medical equipment 4. Holding area for patient on observation 1. When appropriate. The appropriate structure.4.5) are available.2.1. Criteria for admitting patient or registering out patient 1. 5.7. Patient’s physical and cognitive limitation 1. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1.5. adequate time and communication skills to do so.6.6.4.1.5. Measurable Elements 1.6. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4.1 to 4. Process for admitting patient or registering out patient 1.5. Education resources are available and organized in an efficient and effective manner. Treatment and diagnostic procedures IV. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. 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. Pain management 4. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. 3. There is an evidence that nurses who provide education have the subject knowledge.3. it is evident that the patient and family are educated on topics considered high risk to patients: 4. Safe and effective use of medications and their side effects 4. methods and mechanism for education is afforded.4.2.1. Patient’s and family’s language 1. Preventing interactions between prescribed medications and other medications (over the counter) and food 4. Clinical services available 1. Measurable Elements 1. Rehabilitation techniques 4. 2. 4.3. Patient’s and family’s motivations and emotional barriers 1. 6.

4. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. 2. curative. There is an evidence that nurse screening assessment focuses on preventive. curative. 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.2. 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. Measurable Elements 1. There is an evidence that patients with immediate needs/care are assessed. cultural. 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. 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. 2.4.3. There is an evidence that staff who responded to emergency patients underwent the necessary training.1. Measurable Elements 1.5. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. 3. physical. .Expected cost of care 2. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. Sufficient information to make knowledgeable decision and 2.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse.Proposed plan of care 2. Limit or overcome barriers such as language. 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. It is evident that criteria is physiologic-based and developed by appropriate individuals. Expected outcome of care 2. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. Standard V: Continuity of Care In diverse health care setting. Measurable Elements 1.

Between nursing units or clinical departments 1. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge. There is a process on out on pass patients for a defined period of time. 4.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6. out on pass. 2. referral and follow-up congruent with those of the organization. referral and follow-up congruent with those of the organization. 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.Nursing ward services to intensive or special services 1. Diagnostic and therapeutic procedures performed 6. During all phases of care.1.5.8.Measurable Elements 1. 3. Condition of patient at the time of discharge 6. Referral for support services to either health care providers. Continuity of care and coordination of services are evident throughout all phases of care. Medications to be taken at home 6. 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. There is a referral system of patients for transfer to other organization. Other health care settings 2.4. procedures and guidelines regarding the transfer of patient within and outside of the organization. health organizations or agency.7.9. Medications and treatments 6. 3. out on pass. procedures and guidelines on patient’s discharge. identified as responsible for patient care and documented in the patient record. Measurable Elements 1.6.2. Out on Pass. Significant physical and other findings 6.5. Standard VII: Transfer of Patient The Nursing Services Department has established policies. and health professionals in the community.2.Nursing ward services to surgical and non surgical services 1. 6.1.4. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. .3. there is a qualified individual. 5. There are criteria that determine patients readiness to be discharged.7. There are written policies.3. Reason for admission 6. Significant diagnosis and co-morbidities 6. Standard VI: Discharge. Out patient care programs 1.6. Emergency services to nursing ward admission 1. Nursing ward services to diagnostic services 1.

Registration number and or Admission number 1. 2. interventions (medical and nursing) and continuous care rendered are written. Transfer of responsibility to another health provider or health care setting is evident.1. Advance directive 1.4.2. procedure and guidelines on transfer of patient within and outside of the organization. Situation when transfer is not possible is stated. Patient’s addressograph – name. Patient’s transfer is documented.1. Measurable Elements .2. Responsible health care provider during the patient’s transfer is identified. Mode of admission/transport/discharge 1. Attending physician and referring physician. 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. 2.5. stretcher 1.1.6. Summary of patient’s clinical condition. Admitted from: home. 2.3. 2. Formal and informal arrangements are apparent. Admitted via: ambulatory.4. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. 2.9.The guidelines and procedures include but are not limited on the following: 2.8. age.2.7.4. V. Safe and quality medical transport services within and outside of the organization are provided.5. Language spoken 1.3.6. Religion 1. 2. gender. if any 1. wheelchair.4. civil status 1.Measurable Elements 1. 2. care facility 1.7. 2. Transfer is based on the patient’s needs for continuity of care. transferring hospital.8.There is a written policy. Date and time of admission and discharge 1.

There is an accurate and complete documentation of patients’ structural data in all nursing and 1. Physical examination (head-to-toe) 1.2. Measurable Elements 1. accurate and complete nursing documentation of patients’ clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following: 1.1. There is relevant/essential.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. Health history Standard II: Governance Responsibility and Accountability . professional standards and institutional requirements.

responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility. The Nursing Services governance structure is described in written documents with the approval of proper authority. social.Health teachings – patient and family 1. clinical planning and services and policy development. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I.Pharmacological management 1.10.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.Actual and potential health problems and needs 1. 4.7. Psychological.4. 2. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.1.5. Measurable Elements 1. authority. 3. spiritual and economic evaluation 1. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. . The Nursing Services governance structure and processes support professional communication.9.8.3.Diagnostic and therapeutic interventions 1.6.Nursing interventions 1.

Standard II: Governance Responsibility and Accountability . managers. philosophy. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. primarily sets its direction by formulating its vision. There is a written document that describes how the performances of the governing entity are appraised by specific criteria. core values and quality objectives congruent with that of the institution and the Nursing profession. mission. Those responsible for governance appoint the Nursing Services Administrator. The vision. Those responsible for the Nursing Services Department governance. job description and other similar documents.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. 3. attainable. Measurable Elements 1. The governance responsibility and accountability are described in organization’s by-laws. philosophy. 2. 4. core values and quality objectives congruent with that of the institution and the Nursing profession. 2. Standard III: Direction-Setting The Nursing Services Department has an established vision. measurable. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. mission. philosophy and core values are written ( specific. reliable. Measurable Elements 1. mission.

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 . 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. Measurable Elements 1. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. widely disseminated. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. updated. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. action plan/activities. interpreted and operationalized. Measurable Elements 1. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. 3. nursing manpower and unit operation of responsibility areas. 2. ethical and recorded ).time bound. timeframe. reviewed. resources required and contingencies.

Standard VII: Ethico – Moral & Legal Accountabilities The Nursing Services Department has an established framework for ethico-moral and legal management to support the ethical decision-making in the clinical areas. Each Nursing Unit has an individual budget plan periodically monitored for variances. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. 2. 3. regulations and standards. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. 4. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. Measurable Elements 1. and conforms with the applicable statutory laws. Standard VIII: Professional & Organizational Involvement The administrator of the Nursing Services Department actively participates and collaborates with leaders within the organization and professional associations for continuous quality improvement of nursing services. Those responsible for governance ensure compliance with the applicable statutory laws. rules and regulations. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. Measurable Elements 1. professional and interprofessional relationships and other related endeavors. . 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. 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 medical supplies. 3. 2.2. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines.

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. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration. II. RA 9173 appropriate education. n such as: fully responsible and 1.4. Be a member of good standing of the accredited professional organization of nurses. and 1.administration courses at the graduate level. Nursing Measurable Elements Service Admini strators : .1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on. Standards on Human 1.1.

1. Be a regist ered nur se in the Philippi nes.1. 1. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n. 1. with a least nine ( 9) unit s in man age ment and .1.3. 1.2.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. Poss ess a degr ee of bach elor of Scien ce in Nursi ng.

2.1.A person occupying the position of chief nurse of director of nursing service shall.3) of the above.1. 1. and (1. That for chief nurses in .3.1. A master’s degree major in nursing.).4. in addition to the foregoing qualificatio ns. At least five (5) years of experience in a supervisory or management p o s it i o n i n n u r s i n g 1.2. (1. That for primary hospitals . possess: 1. 1. 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 (1.2.1).1. .1.

2.5. Standard II Staffing Plan : . 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. those who have a master’s degree in public health/com munity health nursing shall be given priority.the public health agencies. That for chief nurses in military hospitals. 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 III: Recruitment. hiring. There are legitimate and legitimized processes to recruit. Staff recruitment. The licensure. skills and experience) of Nursing Services staff. 2. selection. verifying and evaluating the nursing staff credentials (licensure. There is evidence of standardized procedure to gather the credentials of all nursing staff. verifying and evaluating the nursing staff credentials. selection. type and desired qualification (education. . The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. level and modality of care. work experience) and other pertinent requirements. hiring and appointment are based on institutional. reviewed and updated on an ongoing basis. education. 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.The Nursing Services Department has a staffing plan that identify the number. Measurable Elements 1. training and work experiences of nursing personnel are documented and updated. reviewed and updated on an ongoing basis. training. Measurable Elements 1. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. 2. type and desired qualification of nursing services staff which is written. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. Measurable Elements 1. hire and appoint nursing services personnel and are uniformly implemented. hiring. patients’ mix. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. Those responsible for Nursing Services governance develop a staffing plan that identify the number. Those responsible for Nursing Services governance consider the organization’s mission. select. 2. Those responsible for Nursing Services governance develop an effective process for gathering. education. 3. 3. staff and skills mix and other factors affecting the projection of staffing needs. 3. Selection. selection. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. type of services. patients’ needs and applicant qualification.

available resources and staff competencies. 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. There is a written Job Description for each position classification of Nursing Services personnel which . There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary.2. which specifies duties and responsibilities based on established standards of performance. Staff placement/assi gnment is based on patient needs. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. Measurable Elements 1. 3. Measurable Elements 1. There are written core competencies required for every job position in the Nursing Services organization to ensure that the staff skills are consistent with the patients’ needs.

Duties and responsibilities 1. Accountability 1. 2. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.2. Functional relationship 1.4.3.1.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. There is evidence of staff development programs for all nursing personnel . Measurable Elements 1.

throughout the year which include: a. Orientatio n program for newly hired and promoted staff. staff and property. Career counseling and career advanceme nt/ladder. Resources are available to implement the staff development program such as: . 3. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. c. Safety program to protect the patient. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties. b. Continuing education. d.

Standards on Facility Management & Environment Safety Standard I Facility Planning : 2. plan and budget for upgrading or replacing key components based on facility inspection findings. List of attendees/participants III. Space and facilities 3. regulations and other requirements that are applicable.g. Title of the program 5. (e.2. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. Audiovisual equipment 3. Measurable Elements 1. destruction or loss. staff and visitors aligned with that of the organization’s master plan. For efficient and effective delivery of nursing care and services.3.3. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use. . Effectiveness of the program 5. Records of staff development program are maintained which include: 5. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. Evaluation of the attendees 5. Educational resources 3.1.5. radio-active materials and waste. the Nursing Services Department provides a safe. Clinical and clerical staff 3.5.4. visitors. Ther e is a wr itten and up-to-date plan. 3. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1. Medication Room) 1. 5. Safety and Security •There is an existing provision for the identification of patient and their families. chemotherapeutic agents. Measurable Elements 1. Those responsible for governance.1.g.4. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment. functional and supportive facility to patients and their families. Program design and content 5.3.1. Resource speakers 4. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning. tampering. Objectives of the program 5.2. staff and others. chemicals. Those responsible for governance comply with relevant laws. Policies and procedures on continuing education staff attendance to staff development programs are evident.6.2.

•A written emergency processes is in place in the event of water interruption or contamination. hazardous materials and wastes. 1. preventive maintenance. processes in a continuous storage. Fire Safety waste). : 1. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing. Standard III Staff Education 1. infectious institutional emergencies.3. 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. 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. • prevention and control programsinvestigation of spills. and medical gases are available 24 hours a day. labeling. procedures and guidelines on infection control are implemented.4. and disasters.6.7.and comprehensive manner to all patient care and staff work areas. use. and recall system. and that E EThere Documentation and reporting system are are infection surveillance. regular inspection. Utilities •Potable water. inventory.hazardous gases and vapors. •Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. seven (7) days a week. inventory and 1. •Monitoring of utilities is evident for . electrical failure or interruption and medical gases unavailability. epidemics.policies. electrical power. Infection Control disposal of hazardous materials E EThere is evidencewaste.

Emergencies •An emergency management plan and processes are evident to likely community/ .purposes of planning and improvement.5. 1.

1.Community The Nursing Services Department has established •Patient/nursing care services policies. procedures and guidelines on patient clinical record. Patients and Families 1.1. E EPolicies. Security of record •Alternative sources of care and services .clinical staff) VI. Directives. Clinical record for every patient assessed or •Patient/nursing care services treated. to patients and their families. Confidentiality of record 1. Mission.4. programs. Core Values demonstrate their role in the aforementioned safety Procedures. procedures. to operate E medical equipment appropriate to their job Activities description. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. •Health programs •Process to access care Measurable Elements 1. nursing personnel and other health professionals throughout the organization. in-patient or out-patient available 1. Standards 3. There is an evidence of staff training EMemorandum. 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. Nursing Personnel E ENursing endorsement in between work shifts 1. 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. Guidelines. There are written policies. There is an evidence that the staff can describe andService Philosophy.1. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs. : : Measurable Elements 1.E EEducational materials and methods in an understandable format and language 1. Vision.2.3. Other Health Professionals (clinical and non.3. E ENursing 2.2. Circular.

6. Process and frequency of review and continued approval of policies and procedures 2.• Protection from loss and destruction and unauthorized access and use 1. Staff Development Programs 1. symbols.2.Quality Improvement Program and other Projects 1. Nursing and the Organization 1.4.6. date of issue.Minutes of Meeting.11. 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.9.1.Master Staffing Plan 1. Measurable Elements 1. Tracking of policy and procedures in circulation (e.10.12. Standards 1. Retention of obsolete policies and procedures 2. title. 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.2. There is a written policy or protocol in keeping and maintaining Nursing Services Department administrative records which include but are not limited on the following: 1. Staffing Pattern 1. Identification of charges in policy and procedures 2. Measurable Elements . Procedures. Committees. authorized person) V. Nursing Services Department 1. Data Integrity •Protection from tampering 1. References originating outside the organization 2.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2.3.5.1. Control that only current policy and procedures are implemented 2.8.g.5. Bed Capacity and Occupancy Rate 1. Use and monitoring of standardized abbreviations. Guidelines 1.6.4.Budget Plan 1.5.Review and approval of all policies and procedures before implementation 2. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2.3. procedure codes and definitions 1.7.7.4. Census of Patients and Diseases 1. Organization and Nursing Services Department Policies.

1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. Clinical research 1. processes and results and data are aggregated. 3. hand hygiene and barrier technique. reporting (needle stick injury.6. Total parenteral nutrition 1.2. (e. 4. Measurable Elements 1. 5.3. 6. Standard II Quality Programs : and other relevant evidence – based information. There is a clinical monitoring that exists but is not limited on the following: 1. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.8.g. Surgical safety (sterilization/disinfection) 1. There is an existing plan and program to reduce the risk of community/hospital acquired infectious for patients and health care associated infections for staff. implemented and monitored for consistent use and effectiveness. . 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. clinical pathway) 2.5. Medication safety. high risk and problemprone processes. monitoring. Blood and blood products 1. There is a training program for staff consistent with their role in quality improvement and patient safety program. Measurable Elements 1. Infection control. scientific literature.1. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. There is an established reporting system on the quality and safety programs to governance. body fluids and waste segregation/disposal) 1. Prevention and control measures aligned with International Patient Safety Goals. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. Medication error 1. guidelines. Intravenous fluids 1. Standard III Quality Monitoring. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice.7. 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. Nursing documentation 1. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure.9. 2. 3 .4. surveillance. 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. analyzed and transformed to useful information. clinical standards.

information technology.g. verifying. use. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. The process determines if an individual can provide patient care services in or for a health care organization. It includes the role of management to produce and control the use of data and information in work activities. if any supplies essential to most patient needs (e. ulation and those in governance and actions taken. and information services. and other specific . sharing and disposal of data or information for effective and efficient operation of organization activities. the treatment rendered. the procedures performed. Communication Management – is the creation. that includes actions for improvement or changes are planned. or spiritual and social care or service. psychological. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care.hat exists but is not limited on the following: iagnoses d complaints. Credentialing – is the process of obtaining. the significant findings. or nursing care. demonstrate that the improvements are effective and sustained. information resources management. the patient’s condition on discharge. This applies within an organization or across multiple organizations. elements of care. tested and implemented. scope and severity of the problems. and assessing the qualifications of a health care practitioner like the nursing personnel. level of medical.

nurse. medications). It is also known as a “health care institution. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment. maintaining quality of care. Indicator – is a measure of the performance of functions.” “board of trustees. Health care professionals are often licensed by a government agency or certified by a professional organization.” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. group or agency that have ultimate authority and responsibility for establishing policy.instructions given to the patient or family (for example. Informed Consent – is an agreement or permission accompanied by full information on the nature. hospitals. systems. or process.” and “governing body. over time. This includes ambulatory care centers. and his/her life expectancy is estimated to be within days or months. Governance – refers to the individual(s).” “board of commissioners. laboratories and long term organizations. risks. and providing for organization management and planning. dentist. home care organizations. follow –up.” board of governors. Other names for this group include “board. behavioral/mental health institutions. and alternatives of a medical procedure or treatment before the . This includes a physician. or allied health professionals.

7 Pearson Education South Asia PTE LTD. physician or other health care professional begins the procedure or treatment. or certification. Patient Record/Clinical Record – is a written account of a variety of patient health information. lists the strategy to meet those needs. The plan of care may include prevention. and documents the individual’s progress in meeting specified goals and objectives. treatment. outlines the criteria for ending intervention. such as assessment findings. usually provided in the workplace. training. Coulter M (2004). progress notes and discharge summary. applicable licensure. care. In-Service Education – is an organized education. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. habilitation. treatment details. . designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines.Robbins. clinical paths or a combination of these. law or regulation. experience. Management. physicians and other health care professionals involved in the care of patients. competence. S. Plan of Care – is a plan that identifies the patient’s care needs. protocols. Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. th Edition. This record is created by nurses. practice guidelines. It is based on data gathered during patient assessment. and rehabilitation. registration. Qualification is determined by the following: education. The format of the plan in some organizations may be guided by specific policies and procedures. documents treatment goals and objectives.

Inc. Republic of the Philippines. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990).opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge. Inc. . Human Resources for Hospitals. or process that must be in place for escribe the responsibilities for which t to receive. Hollenback. and service. REFERENCES an organization to provide safe and high-quality care. Philippines. Edition Printed in USA 54321 Noe. Credentialing. Metro Manila ctures. New York Republic Act 9173 or The Philippine Nursing Act of 1991. treatment. Gerhart. The Administration of Hospital Nursing Services in Philippine Department of Health. Wright (2004). McGraw-Hill Co. 1 st Edition Joint Commission International (2008). and other persons. Fundamental of Human Resource Management. Inc. 3 rd Edition Printed in USA 54321 Joint Commission International (2004). Accreditation Standards for Hospitals. and Philippine Nurses Association. (1999). including health care providers. Edition Printed in USA 54321 Joint Commission International (2004). Inc. Association of Nursing Service Administrators of the nursing practitioners are accountable.

Nurse’s Handbook of Health Assessment. 7 th Edition Weber.M (2004). Nursing Administration Handbook. Coulter M (2004). S. Guide to Nursing Management and Leadership. th Editi Rowland H & Rowland B (1980). 7 Pearson Education South Asia PTE LTD. J (2006). 5 Edition. Aspen Publication Tomey A.Robbins. Management. Lippincott Williams & Wilkins th .

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