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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.
These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. There are seven (7) criteria that guide the nurses regarding the importance of access to care. Standards on Access and Continuity of Care.also is the medication management and the family rights. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified. . III. IV.
Standards on Human Resource Management . organization and controlling functions of the nursing service administration and their relationship with other services. direction. which include documentation of significant data both structure. V. There are five (5) standards identified: I. 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. professional standards and institutional requirements. need for organizational structure which will delineate responsibility. These focus also on planning. and clinical based on applicable laws and regulations. Standards on Nursing Documentation . There are two identified criteria under this component. Standards on Governance and Direction . accountability and authority of nursing administration. This concerns managing the nursing services in the hospital. This chapter recommends the . II. It The second part is the Administration and Management. There are seven (7) criteria included.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles.
III. . It also enables the chief nurses/adminis trator to develop a specific hospital system which is efficient and effective. administration record and communication of information. Three (3) criteria are identified focusing on the patient’s record. Standards on Facility Management and Environmental Safety . Standards on Quality Improvement . This standard has three (3) criteria which address the need to institutionalize V.also includes staffing modalities depending on the type of services. This standard contains three (3) criteria and covers environmental safety IV. 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.
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 nursing care prioritize patients’ needs based on assessment results. 2. Measurable Elements 1. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. 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. 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. Pain is . Psychological •Knowledge level •Language spoken •Barriers to learning 1.2. individual needs or (e. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following: 1.0. erval appropriate to patient’s condition.g. 1. plan of care.
Cognitive Pattern .Preference and idiosyncrasies 1. Spiritual •Religion 1. Social •Cultura l concerns 22.214.171.124.5. Vital signs 1. skilled care facility •Individual who will accompany the patient home (name.10.1. needs and risks 1.9. extended.Coping – Stress Tolerance Pattern 1. Sleep – Rest Pattern 2. There is an established screening criteria according to patients’ functional capacity and needs like: 2. Activity – Exercise Pattern 2. Elimination Pattern 2.9. address.6.7. Role – Relationship Pattern 2. Nutritional – Metabolic Pattern 2. Pain assessment 1.11.Discharge plan •Place: home. telephone number.8.• Sensory assessment 1.7. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 126.96.36.199.2. Sexuality – Reproductive Pattern 2. relationship) 2.10. Economic factor •Financial barrier 1.3. Self – Concept Pattern 2. Nutritional status. Sensory – Perceptual Pattern 2.
5. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care.1.2.Value – Belief Pattern 3. There are existing policies and procedures on care process developed by those responsible for governance which include . 5. Age 5. Measurable Elements 1.2. 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. Continuing medical and nursing needs 5. Lack of mobility 5.Referral for continuity of care as necessary II.11.4. technique and instruments. but are not limited on the following: 4. 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. Assistance with activities of daily living 5. Other pertinent data are collected using the appropriate assessment.3.
5.13. 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. 1. The care plan is documented in the individual patient’s record to promote continuity of care. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for.4. 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: . alleviation of suffering and restoration of health.8.3. There is an evidence that family and significant others are involved in the planning process. ventilatory equipment) Care of patient on dialysis (hemodialysis. prevention of illness. 2. There is a written care plan on every patient cared of by the nurse based on patient’s initial assessment data within the 1 st 24 hours of assessment or earlier. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e. Care of patient on chemotherapy 1. 1. Care of perioperative patient 1. Care of patient in restraint 1. Measurable Elements 1. 6. •Disabled 1.12. Care of patient in pain 1. religious and other beliefs of patients. 3.9.suppressed patients 1.14. 5. Care of patient on nutritional therapy 1.1. The care plan ensures that priorities of care are established.6.11.15. 4. Care of comatose patient 1. Patient participate in planning of care taking into consideration the cultural. Care of patient receiving medications with narrow margin of safety 1. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2. Measurable Elements 1. Care of immune . 1.g.1.10.1. Care of patient receiving blood and blood components 1.7. Care of patient with communicable diseases 1. The care plan is updated as appropriate based on the reassessment made. 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.
2. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess.1. Evidence . monitor. 2. monitor. There is an existing pain management guideline for nurses to appropriately assess. Scope of Nursing Practice as provided by law and all relevant legislations (e. evaluate and manage patients in pain.based practice 1.g.5. 3. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations.Code of Ethics for Nurses 1. Standard IV: Evaluation of Care Measurable Elements 1. Standard of Care: •Acute and Critical Care Nursing Practice •Chronic Care Nursing Practice •Cardiovascular Nursing Practice •Perioperative Nursing Practice •Maternal and Child Nursing Practice •Psychiatric Nursing Practice •Emergency Nursing Practice •Renal Nursing Practice •Pediatric Nursing Practice •Oncology Nursing Practice •Geriatric Nursing Practice •Ethical and Legal Nursing Practice •Nursing Standard on Intravenous Therapy •Infection Control Nursing Practice 1. Patient Bill of Rights 2. There is an evidence that patient’s responses to interventions are documented.1. Ten (10) Golden Rules in Drug Administration 1. There is evidence that patients receive care according to pain management guidelines.6. The Philippine Nursing Act of 2002 or Republic Act 9173) The nurse caring for patients systematically and continuously evaluates the patient’s progress based on the effectiveness of nursing intervention rendered and medical management provided.4. evaluate and manage patients in pain.3. 4. . 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. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. Measurable Elements 1. 1.2. The revision in care plan if any is reflected in the patient record.
3.Regulated Drugs 1.1. Standard VI: Medication Management The Nursing Services Department has established policies.2. Documenting 1.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1.1. Measurable Elements 1.5.6. procedures and guidelines on medication management for symptomatic. Monitoring and Storage 1. In accordance to statutory laws. .2. 1. 4. are monitored and recorded. preventive. 2. 1.2. Processes to communicate with and evaluate patients and families about pain are evident.8. Living will if any. There are existing education and training programs for nurses on pain management. Labeling 1.10. intervention and evaluation. are respected. Transcribing and ordering 1.1. Preparing 1.Medication Recall System (Expired or Outdated Drugs) 1.7.9. 1. psychological. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment. Advance directives Do Not Resuscitate.4. Assessment. religion and cultural preferences and practices is evident. Pastoral services are provided based on the spiritual beliefs of the patient and family. rules and regulations. There are written policies. Endorsing (especially high valuable drugs) 1. and palliative treatment of patients’ diseases and for safe nursing practice.12.4. Pain assessment. Waiver. The patient’s right of self-determination and choices are respected and accommodated. 1. Carrying out physician’s medication order 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. Respect for patient’s values.3. Administering (10 Golden Rules in Drug Administration) 1. procedures and guidelines on medication management which include but are not limited on the following: 1. curative.11. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. Emergency Drugs 1. Personal hygiene is rendered based on patient’s need. 2. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. 2.
Respect for patient’s personal values and beliefs 1.1. treatment. emotional. Patient’s and family’s educational level . 1. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies. Protection of patient’s possessions from theft or loss 1.4. Measurable Elements 1. Patient’s and family’s beliefs and values 1. vulnerable patients are infants. Patient’s and family’s literacy 1. 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. transport) 1. Respect the confidentiality of patient health information 1.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration.2. outcome of care. during treatment. spiritual and cultural concerns.2. 3. 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. processes and guidelines that respect and support patient and family rights. procedure.2.3.3. 4. Standards on Patient and Family Education Standard I: Education Assessment The nurse assesses the educational needs of each patient and family and documents these in his/her patient record.Respect for patient’s need for privacy (e. The patient and family are involved in care management and decision. III. children and elderly) 1.g.6. clinical interview. 2. A place is designated for the patient’s family to stay. There are written policies.3. Measurable Elements 1.g. There is evidence that nurses are knowledgeable and supportive of patient and family rights. Interventions address patient and family’s psychosocial.5. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1.1. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. physical examination. Protection of patient from physical assault (e.4.7. unanticipated outcome and participation in care decision according to wishes •Informed consent •Refusal or discontinuance of treatment •Withholding life-sustaining treatments •Assessment and management of pain •Compassionate care at the end-of-life •Process on complaints and differences of opinion about patient care •Participation in clinical research •Organ donation and other tissues •Disclosure of information 2.
Patient’s physical and cognitive limitation 1. When appropriate. 5. Pain management 4.3.7. it is evident that the patient and family are educated on topics considered high risk to patients: 4. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. Preventing interactions between prescribed medications and other medications (over the counter) and food 4.5. 4.5) are available.5.2. Clinical services available 1.3. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients .6. 6. Safe and effective use of medical equipment 4.4. Criteria for admitting patient or registering out patient 1. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1. Education resources are available and organized in an efficient and effective manner. Holding area for patient on observation 1.5.1 to 4. Patient’s and family’s language 1. adequate time and communication skills to do so. There is an evidence that nurses who provide education have the subject knowledge.2. 3. Process for admitting patient or registering out patient 1. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1.4. 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. Measurable Elements 1.1. Rehabilitation techniques 4.4. methods and mechanism for education is afforded. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting. 188.8.131.52. Patient’s and family’s motivations and emotional barriers 1. Treatment and diagnostic procedures IV. Safe and effective use of medications and their side effects 4.1. Measurable Elements 1. The appropriate structure.
Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive. 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.Expected cost of care 2. 2. . Standard V: Continuity of Care In diverse health care setting. curative. rehabilitative and palliative services as well as other relevant information are assessed and prioritized based on his/her health condition at the time of admission in the health care facility. 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. 3. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs.2. physical. Measurable Elements 1. Measurable Elements 1.5. There is an evidence that nurse actively participated in providing relevant information to patient and family during the admission process which includes but are not limited on the following: 2. 4. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. 2. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. It is evident that criteria is physiologic-based and developed by appropriate individuals. Measurable Elements 1. Expected outcome of care 2.Proposed plan of care 2. There is an evidence that patients with immediate needs/care are assessed. cultural.4.3. 2. Sufficient information to make knowledgeable decision and 2. curative. There is an evidence that nurse screening assessment focuses on preventive. Limit or overcome barriers such as language. 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.1. There is an evidence that staff who responded to emergency patients underwent the necessary training.
2. Standard VI: Discharge. Measurable Elements 1. There are criteria that determine patients readiness to be discharged.Nursing ward services to surgical and non surgical services 1.4. referral and follow-up congruent with those of the organization.Measurable Elements 1.7. Significant diagnosis and co-morbidities 6.5. 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: 1.6. Condition of patient at the time of discharge 6. Diagnostic and therapeutic procedures performed 6. 4.2.3. 3.Nursing ward services to intensive or special services 1. During all phases of care. Significant physical and other findings 6. Other health care settings 2. Standard VII: Transfer of Patient The Nursing Services Department has established policies.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6.6. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge. 6. Nursing ward services to diagnostic services 1. .2.8. There is a process on out on pass patients for a defined period of time. referral and follow-up congruent with those of the organization. there is a qualified individual. Reason for admission 6. Continuity of care and coordination of services are evident throughout all phases of care. Out patient care programs 1. procedures and guidelines regarding the transfer of patient within and outside 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. Referral for support services to either health care providers. out on pass.9. There is a referral system of patients for transfer to other organization. and health professionals in the community. procedures and guidelines on patient’s discharge.1. 5. Out on Pass.4.5. Medications to be taken at home 6.7. health organizations or agency. Between nursing units or clinical departments 1. There are written policies. 3. Medications and treatments 6. out on pass. identified as responsible for patient care and documented in the patient record. Emergency services to nursing ward admission 1.3.1. The patient’s discharge summary is prepared by qualified individuals recognized by the organization.
procedure and guidelines on transfer of patient within and outside of the organization.2.4. Patient’s addressograph – name. Date and time of admission and discharge 1. 2.4. Transfer of responsibility to another health provider or health care setting is evident. Summary of patient’s clinical condition. Responsible health care provider during the patient’s transfer is identified. V.6.4. interventions (medical and nursing) and continuous care rendered are written. if any 1. Language spoken 1.5. Advance directive 1.7.8. Health Care Insurance Standard II: Clinical Data The nurse documents essential clinical data of each patient accurately and completely based on individualized nursing care plan from admission to discharge in health care facility.Measurable Elements 1. Religion 1. transferring hospital.8. Safe and quality medical transport services within and outside of the organization are provided. 2. Measurable Elements . Attending physician and referring physician. Mode of admission/transport/discharge 1. Formal and informal arrangements are apparent. 2. wheelchair. 184.108.40.206.1.9. 2.5. Transfer is based on the patient’s needs for continuity of care. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. gender.There is a written policy. Patient’s transfer is documented. 2. age.4. Admitted from: home. Situation when transfer is not possible is stated.2.3. 2. 2. care facility 1. civil status 1. Admitted via: ambulatory.7.3.The guidelines and procedures include but are not limited on the following: 2. stretcher 1. Registration number and or Admission number 1.2.
Health history Standard II: Governance Responsibility and Accountability . 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. There is an accurate and complete documentation of patients’ structural data in all nursing and 1. Physical examination (head-to-toe) 1.1. professional standards and institutional requirements. There is relevant/essential.2. Measurable Elements 1.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations.
spiritual and economic evaluation 1.Patients’ response and outcome 1. Psychological. 4. 3. The Nursing Services governance structure is described in written documents with the approval of proper authority. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.6. Measurable Elements 1.10. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.9. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I.Pharmacological management 1. 2. clinical planning and services and policy development. responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility.Health teachings – patient and family 1. The Nursing Services governance structure and processes support professional communication.8.Nursing interventions 220.127.116.11.Actual and potential health problems and needs 1. social.4. authority. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. .7.Diagnostic and therapeutic interventions 1.
primarily sets its direction by formulating its vision. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. core values and quality objectives congruent with that of the institution and the Nursing profession. Measurable Elements 1. 3. core values and quality objectives congruent with that of the institution and the Nursing profession. 2. mission. job description and other similar documents. 4. Those responsible for governance appoint the Nursing Services Administrator. reliable.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. mission. managers. Those responsible for the Nursing Services Department governance. 2. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. The vision. philosophy and core values are written ( specific. Measurable Elements 1. 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 . The governance responsibility and accountability are described in organization’s by-laws. attainable. philosophy. Standard III: Direction-Setting The Nursing Services Department has an established vision. philosophy. mission. measurable.
Standard V: Financial Plan & Resource Allocation The Nursing Services Department has financial plan and allocation of resources required to meet its goals and sustain its operation. Measurable Elements 1. widely disseminated. interpreted and operationalized. resources required and contingencies. 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. 2. Measurable Elements 1. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives.time bound. action plan/activities. Those responsible for governance have established current financial plans and allocation of resources . ethical and recorded ). reviewed. 3. nursing manpower and unit operation of responsibility areas. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. timeframe. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. updated.
An updated manual of Nursing Services policies and procedures exists and provides clear directive for nursing personnel at different levels on the scope and limitations of their functions and responsibilities to patient care.2. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. Those responsible for governance ensure compliance with the applicable statutory laws. regulations and standards. Measurable Elements 1. 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 develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. rules and regulations. 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. 2. and conforms with the applicable statutory laws. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. 2. 4. 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. Measurable Elements 1. Each Nursing Unit has an individual budget plan periodically monitored for variances. 3. 3. Measurable Elements 1. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. . professional and interprofessional relationships and other related endeavors.
Standards on Human 1. n such as: fully responsible and 1.1. Nursing Measurable Elements Service Admini strators : .administration courses at the graduate level. and 1. RA 9173 appropriate education.1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on.4. II. There are Resource Management presence of Standard I: evidences Administrator of that the Nursing Services Nursing Service The Nursing Administra Services Department tor is is administered by a qualified qualified nursing to the administrator position pertinent to based on licensure. Be a member of good standing of the accredited professional organization of nurses. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration.
1. 1. Poss ess a degr ee of bach elor of Scien ce in Nursi ng.2.1. 1. Be a regist ered nur se in the Philippi nes.1.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. 1.3. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n. with a least nine ( 9) unit s in man age ment and .
possess: 1. in addition to the foregoing qualificatio ns. and (1.3) of the above. a n d 18.104.22.168.). (1.1.2. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1. 1. 1.3. That for primary hospitals .2.A person occupying the position of chief nurse of director of nursing service shall.1. At least five (5) years of experience in a supervisory or management p o s it i o n i n n u r s i n g 1.4. That for chief nurses in .1.1).1. A master’s degree major in nursing. .
Standard II Staffing Plan : . priority shall be given to those who have finished a master’s degree in nursing and the completio n of the General Staff Course (GSC).the public health agencies. 2. those who have a master’s degree in public health/com munity health nursing shall be given priority. That for chief nurses in military hospitals. Those responsible for the overall administration and management of Nursing Services is a member of the top Executive/Ma nagement Committee who participates in their regular meetings and provides advice and recommendati ons in relation to nursing practice. 1.5.
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. There is evidence of standardized procedure to gather the credentials of all nursing staff. 2. hiring and appointment are based on institutional. selection. selection. The licensure. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. patients’ mix. verifying and evaluating the nursing staff credentials (licensure. level and modality of care. 3. 2. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. hire and appoint nursing services personnel and are uniformly implemented. training. Measurable Elements 1. reviewed and updated on an ongoing basis. 3. training and work experiences of nursing personnel are documented and updated. Those responsible for Nursing Services governance develop a staffing plan that identify the number.The Nursing Services Department has a staffing plan that identify the number. Standard III: Recruitment. . 3. skills and experience) of Nursing Services staff. type and desired qualification of nursing services staff which is written. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. education. select. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. type and desired qualification (education. Measurable Elements 1. Those responsible for Nursing Services governance consider the organization’s mission. education. 2. work experience) and other pertinent requirements. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. patients’ needs and applicant qualification. verifying and evaluating the nursing staff credentials. hiring. Measurable Elements 1. Those responsible for Nursing Services governance develop an effective process for gathering. Selection. There are legitimate and legitimized processes to recruit. type of services. hiring. reviewed and updated on an ongoing basis. selection. staff and skills mix and other factors affecting the projection of staffing needs. Staff recruitment. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment.
2. Measurable Elements 1. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. 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 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. Measurable Elements 1. available resources and staff competencies. which specifies duties and responsibilities based on established standards of performance. 3.2. Staff placement/assi gnment is based on patient needs. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. There is a written Job Description for each position classification of Nursing Services personnel which .
Duties and responsibilities 1. There is evidence of staff development programs for all nursing personnel . 2.specifies: 1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.2.4.3. Accountability 1. Measurable Elements 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. Functional relationship 1.1.
Continuing education. Safety program to protect the patient. Resources are available to implement the staff development program such as: . b. c. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills. d.throughout the year which include: a. staff and property. Orientatio n program for newly hired and promoted staff. Career counseling and career advanceme nt/ladder. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties. 3.
Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. regulations and other requirements that are applicable. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use. 3. Educational resources 3. Title of the program 5.6. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning.2. staff and others. Those responsible for governance comply with relevant laws.1. Audiovisual equipment 3. Measurable Elements 1.1. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment. Effectiveness of the program 5. . Space and facilities 3. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2.g. Program design and content 22.214.171.124.2.3. Measurable Elements 1. Clinical and clerical staff 3. For efficient and effective delivery of nursing care and services. Safety and Security •There is an existing provision for the identification of patient and their families. Objectives of the program 5. staff and visitors aligned with that of the organization’s master plan. Records of staff development program are maintained which include: 5. Medication Room) 1. List of attendees/participants III. plan and budget for upgrading or replacing key components based on facility inspection findings. Evaluation of the attendees 5. radio-active materials and waste. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1.3. Resource speakers 4.5. chemotherapeutic agents. the Nursing Services Department provides a safe. chemicals. Ther e is a wr itten and up-to-date plan.4.4. Those responsible for governance. (e. Policies and procedures on continuing education staff attendance to staff development programs are evident. visitors. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. tampering. functional and supportive facility to patients and their families. 5.3.g. destruction or loss.
electrical failure or interruption and medical gases unavailability. procedures and guidelines on infection control are implemented. and medical gases are available 24 hours a day. use.7.4. epidemics. and recall system. processes in a continuous storage. and disasters. •Monitoring of utilities is evident for . 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.3. labeling. hazardous materials and wastes. 1. infectious institutional emergencies. •Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. inventory. regular inspection. • prevention and control programsinvestigation of spills. Utilities •Potable water. Infection Control disposal of hazardous materials E EThere is evidencewaste. •A written emergency processes is in place in the event of water interruption or contamination. preventive maintenance.policies. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing.6. electrical power. Standard III Staff Education 1. and that E EThere Documentation and reporting system are are infection surveillance.hazardous gases and vapors. inventory and 1. Medical Equipment •There is and Nursing Services Department ensures educationan updated policy andstaff to effectively carry out their roles in creating training of a safe and sound patient and processes on medical equipment asurable Elements procurement. : 1.and comprehensive manner to all patient care and staff work areas. Fire Safety waste). seven (7) days a week.
purposes of planning and improvement. 1.5. Emergencies •An emergency management plan and processes are evident to likely community/ .
E EEducational materials and methods in an understandable format and language 1. Core Values demonstrate their role in the aforementioned safety Procedures. E EPolicies. and •Patient health condition guidelines on patient clinical record which include •Care provided to patient but are not limited on the following: •Patient’s response to care 1. procedures. nursing personnel and other health professionals throughout the organization.3.1. •Health programs •Process to access care Measurable Elements 1.2. Nursing Personnel E ENursing endorsement in between work shifts 1.Community The Nursing Services Department has established •Patient/nursing care services policies.2. 1. There is an evidence that the staff can describe andService Philosophy. There is an evidence of staff training EMemorandum. procedures and guidelines on patient clinical record. Other Health Professionals (clinical and non.clinical staff) VI. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs. Standards 3. Patients and Families 1. There are written policies.3. Circular. Security of record •Alternative sources of care and services . There is efficient and effective system of communication that exist which include but are not limited on the following: 1. to operate E medical equipment appropriate to their job Activities description. Mission.4. to patients and their families.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. Confidentiality of record 1. Clinical record for every patient assessed or •Patient/nursing care services treated. : : Measurable Elements 1. programs. Guidelines. Vision. E ENursing 2. Directives. in-patient or out-patient available 1.
title. Standards 1. Tracking of policy and procedures in circulation (e.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2. authorized person) V. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2.7.9.Budget Plan 1.4. Measurable Elements 1. Control that only current policy and procedures are implemented 2. Use and monitoring of standardized abbreviations.• Protection from loss and destruction and unauthorized access and use 1.Minutes of Meeting. Process and frequency of review and continued approval of policies and procedures 2. Nursing and the Organization 1.1. Committees.3.2. Bed Capacity and Occupancy Rate 126.96.36.199.10.4.Quality Improvement Program and other Projects 1. Nursing Services Department 1. Identification of charges in policy and procedures 2.g.6. 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. procedure codes and definitions 1.4.5. Retention of obsolete policies and procedures 2. date of issue. Census of Patients and Diseases 1. Guidelines 1. Procedures.Review and approval of all policies and procedures before implementation 2.5. 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.188.8.131.52. Organization and Nursing Services Department Policies.Master Staffing Plan 1. References originating outside the organization 2.2.6. symbols.3. Data Integrity •Protection from tampering 1. Staffing Pattern 1. Staff Development Programs 1. Measurable Elements .
reporting (needle stick injury. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs. 2.1. Those in governance support and take action on recommendation for quality improvement and patient and staff safety programs based on the result of root cause analysis. Standard II Quality Programs : and other relevant evidence – based information.g. There is a clinical monitoring that exists but is not limited on the following: 1. scientific literature. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. Medication error 1. . implemented and monitored for consistent use and effectiveness.5. clinical standards. 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. 3. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. There is a training program for staff consistent with their role in quality improvement and patient safety program. Intravenous fluids 1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. Measurable Elements 1. Nursing documentation 1. 4. Clinical research 1.2. Standard III Quality Monitoring. (e. Surgical safety (sterilization/disinfection) 1. Blood and blood products 1. 5. guidelines. Infection control.6. There is an established reporting system on the quality and safety programs to governance. 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. 6. surveillance. Measurable Elements 1.4.9. Total parenteral nutrition 1.1.3. processes and results and data are aggregated. Medication safety.8. 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. hand hygiene and barrier technique. Prevention and control measures aligned with International Patient Safety Goals. body fluids and waste segregation/disposal) 1. high risk and problemprone processes. analyzed and transformed to useful information. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.7. 3 . clinical pathway) 2. monitoring.
demonstrate that the improvements are effective and sustained.g. It includes the role of management to produce and control the use of data and information in work activities. level of medical. information resources management. Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. information technology. scope and severity of the problems. and information services. the treatment rendered. the significant findings. sharing and disposal of data or information for effective and efficient operation of organization activities. The process determines if an individual can provide patient care services in or for a health care organization. or spiritual and social care or service. elements of care. if any supplies essential to most patient needs (e. verifying. use. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. ulation and those in governance and actions taken. and assessing the qualifications of a health care practitioner like the nursing personnel. that includes actions for improvement or changes are planned. This applies within an organization or across multiple organizations. the procedures performed. psychological. and other specific . or nursing care. Credentialing – is the process of obtaining. tested and implemented. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting. the patient’s condition on discharge.hat exists but is not limited on the following: iagnoses d complaints. Communication Management – is the creation. Discharge Summary – is a section of patient record that summarizes the reasons for admittance.
This includes a physician. medications). laboratories and long term organizations. It is also known as a “health care institution. and providing for organization management and planning. group or agency that have ultimate authority and responsibility for establishing policy. or allied health professionals. Other names for this group include “board. dentist. home care organizations. maintaining quality of care. follow –up.” board of governors. Informed Consent – is an agreement or permission accompanied by full information on the nature. or process.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. risks.” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services.” and “governing body. Governance – refers to the individual(s). and alternatives of a medical procedure or treatment before the . systems. behavioral/mental health institutions. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment. over time. hospitals. Indicator – is a measure of the performance of functions.” “board of commissioners. and his/her life expectancy is estimated to be within days or months.instructions given to the patient or family (for example.” “board of trustees. nurse. Health care professionals are often licensed by a government agency or certified by a professional organization. This includes ambulatory care centers.
and rehabilitation. treatment. usually provided in the workplace. 7 Pearson Education South Asia PTE LTD. applicable licensure.Robbins. In-Service Education – is an organized education. practice guidelines. protocols. Patient Record/Clinical Record – is a written account of a variety of patient health information. such as assessment findings. S. outlines the criteria for ending intervention. experience. The plan of care may include prevention. th Edition. progress notes and discharge summary. competence. and documents the individual’s progress in meeting specified goals and objectives. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. law or regulation. habilitation. The format of the plan in some organizations may be guided by specific policies and procedures. This record is created by nurses. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. registration. training. Coulter M (2004). physician or other health care professional begins the procedure or treatment. or certification. care. It is based on data gathered during patient assessment. documents treatment goals and objectives. physicians and other health care professionals involved in the care of patients. Plan of Care – is a plan that identifies the patient’s care needs. treatment details. Management. Qualification is determined by the following: education. lists the strategy to meet those needs. clinical paths or a combination of these. .
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7 th Edition Weber. Lippincott Williams & Wilkins th . Nursing Administration Handbook. S. Guide to Nursing Management and Leadership. Aspen Publication Tomey A.M (2004). 7 Pearson Education South Asia PTE LTD. 5 Edition. Coulter M (2004). th Editi Rowland H & Rowland B (1980). Nurse’s Handbook of Health Assessment. J (2006).Robbins. Management.