This action might not be possible to undo. Are you sure you want to continue?
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.
IV. There are seven (7) criteria that guide the nurses regarding the importance of access to care. . These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. Standards on Access and Continuity of Care.also is the medication management and the family rights. III. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified.
Standards on Nursing Documentation . There are two identified criteria under this component. which include documentation of significant data both structure. accountability and authority of nursing administration. 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. V. Standards on Governance and Direction . professional standards and institutional requirements. direction. need for organizational structure which will delineate responsibility. There are seven (7) criteria included.needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. organization and controlling functions of the nursing service administration and their relationship with other services. It The second part is the Administration and Management. This chapter recommends the . II. These focus also on planning. Standards on Human Resource Management . This concerns managing the nursing services in the hospital. and clinical based on applicable laws and regulations.
This standard contains three (3) criteria and covers environmental safety IV.also includes staffing modalities depending on the type of services. 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. III. Three (3) criteria are identified focusing on the patient’s record. . Standards on Facility Management and Environmental Safety . administration record and communication of information. Standards on Quality Improvement .
.continuous quality and performance improvement. 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.
plan of care. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information. Physical •Neurological assessment according to institutional policies and procedures •Cardiovascular assessment •Respiratory assessment •Gastrointestinal assessment •Genitourinary assessment •Musculoskeletal assessment •Intergumentary assessment CLINICAL SERVICES me.g. Pain is . Those responsible for direct nursing care prioritize patients’ needs based on assessment results. 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. Psychological •Knowledge level •Language spoken •Barriers to learning 1. erval appropriate to patient’s condition. Measurable Elements 1. Those responsible for direct patient care inform the patient and family of the assessment outcome and the planned care and treatment regimen and encourage participation of the latter in the decisionmaking about the priority needs to be met.1. Standard II: Assessment Scope & Content The scope and content of nursing assessment are well defined in an institutional policy wherein those elements common to all assessments and any differences with other health disciplines are identified. individual needs or (e.0. 1. 2.2.
11.Discharge plan •Place: home. needs and risks 1.1. Health history •Developmental history (for pediatrics) •Family history •Medications taken •Allergies 2.8.7. extended.2.3. Sexuality – Reproductive Pattern 2. Sleep – Rest Pattern 2. Social •Cultura l concerns 1.5. There is an established screening criteria according to patients’ functional capacity and needs like: 2.4.3. Spiritual •Religion 1.5. Pain assessment 1. Role – Relationship Pattern 2.10. relationship) 18.104.22.168. Activity – Exercise Pattern 2.6. skilled care facility •Individual who will accompany the patient home (name. Nutritional status.10.Coping – Stress Tolerance Pattern 1.9. Self – Concept Pattern 2.7.Preference and idiosyncrasies 1. Economic factor •Financial barrier 1.8. Sensory – Perceptual Pattern 2. Vital signs 1. Elimination Pattern 2. telephone number. address. Nutritional – Metabolic Pattern 2. Cognitive Pattern .• Sensory assessment 1.
11. but are not limited on the following: 4. technique and instruments. Measurable Elements 1. Lack of mobility 5. There are existing policies and procedures on care process developed by those responsible for governance which include .Value – Belief Pattern 3. 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: 22.214.171.124. Continuing medical and nursing needs 5.3. Other pertinent data are collected using the appropriate assessment. 5.Referral for continuity of care as necessary II. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. Assistance with activities of daily living 5. Age 5.1. 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.4.
15. Care of perioperative patient 1. Example: Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. peritoneal dialysis) Care of patients at risk: •Neonates • Critically-ill •Children • Mentally disadvantaged •Elderly • Under anesthesia 2.11. There is an evidence that family and significant others are involved in the planning process.4.14. prevention of illness. •Disabled 1.13. Measurable Elements 1. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e.12.7. Patient participate in planning of care taking into consideration the cultural. 6. Care of patient in pain 1. 1.6. 3.1. 5. Care of patient with communicable diseases 1. Care of patient receiving medications with narrow margin of safety 1. 2. 4. 1.3. The care plan ensures that priorities of care are established. religious and other beliefs of patients.suppressed patients 1. Care of patient in restraint 1.2.g. 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: . Care of patient on chemotherapy 1. The care plan is updated as appropriate based on the reassessment made.8. alleviation of suffering and restoration of health.5. Care of comatose patient 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.1. Measurable Elements 1. Care of patient receiving blood and blood components 1. Care of immune . Care of patient on nutritional therapy 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.10.1. The care plan is documented in the individual patient’s record to promote continuity of care. 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. ventilatory equipment) Care of patient on dialysis (hemodialysis. 1.9.
Ten (10) Golden Rules in Drug Administration 1.5. The revision in care plan if any is reflected in the 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. Measurable Elements 1. Evidence .Code of Ethics for Nurses 1. monitor. There is evidence that patients receive care according to pain management guidelines. 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.2. 2. Patient Bill of Rights 2.1. There is an evidence that patient’s responses to interventions are documented. evaluate and manage patients in pain. . There is an existing pain management guideline for nurses to appropriately assess. 1. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations. Scope of Nursing Practice as provided by law and all relevant legislations (e. monitor.3. 3.6.4.based practice 1. Standard V: Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record. 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.g. evaluate and manage patients in pain. 4. 2.1. Standard IV: Evaluation of Care Measurable Elements 1.
10.3. Living will if any. 4. intervention and evaluation.Regulated Drugs 1.3.1. Preparing 1.11. preventive.5. The patient’s right of self-determination and choices are respected and accommodated. social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment. Personal hygiene is rendered based on patient’s need.8. appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident. 2.Medication Recall System (Expired or Outdated Drugs) 1. Emergency Drugs 1.7. 1. Pastoral services are provided based on the spiritual beliefs of the patient and family. and palliative treatment of patients’ diseases and for safe nursing practice.12. Processes to communicate with and evaluate patients and families about pain are evident. Advance directives Do Not Resuscitate.3. There are written policies. psychological.2. religion and cultural preferences and practices is evident. 1. 1. are respected. Waiver. Administering (10 Golden Rules in Drug Administration) 1. There are existing education and training programs for nurses on pain management. Documenting 1. 1. procedures and guidelines on medication management which include but are not limited on the following: 1. Patient and family choices to donate organs and other tissue are supported through provision of relevant information.9.1. 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. . Monitoring and Storage 1. Assessment.1. rules and regulations. Measurable Elements 1. Respect for patient’s values.6. are monitored and recorded.2. Labeling 1.Reporting on •Medication effects and adverse effects •Medication error and near-miss Standard VII: Measurable Elements 1. Pain assessment. Standard VI: Medication Management The Nursing Services Department has established policies. curative. 2. 2. Transcribing and ordering 1.2.4. In accordance to statutory laws. Carrying out physician’s medication order 1.4. Endorsing (especially high valuable drugs) 1. procedures and guidelines on medication management for symptomatic.
There are written policies. 4.g.Respect for patient’s need for privacy (e. emotional.4. Standard VIII: Patient and Family Rights The Nursing Services Department has established policies. The patient and family are involved in care management and decision. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. III.1. processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. Respect the confidentiality of patient health information 1. 2. Measurable Elements 1. Measurable Elements 1.7.3.Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. children and elderly) 1. Patient’s and family’s beliefs and values 1. Protection of patient’s possessions from theft or loss 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. 3. physical examination.g.4.2. Respect for patient’s personal values and beliefs 1. outcome of care.3.6. 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: 1.3. procedure. during treatment. spiritual and cultural concerns. clinical interview. Patient’s and family’s literacy 1. Interventions address patient and family’s psychosocial. 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. A place is designated for the patient’s family to stay. There is evidence that nurses are knowledgeable and supportive of patient and family rights. Patient’s and family’s educational level . Protection of patient from physical assault (e.1. treatment. vulnerable patients are infants. 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. transport) 1.2. processes and guidelines that respect and support patient and family rights. 1.5.2.
methods and mechanism for education is afforded. Triage or screening • There is evidence that tr iaging or screening is initiated at the point of 1 contact with the patient 1. Patient’s willingness to receive information Standard II: Education Plan and Programs The Nursing Services Department has established educational plans and programs that support patient and family participation in care decisions and care processes with the primary objective of rehabilitating the patient back to his/her functional level and optimal health. Safe and effective use of medical equipment 4.6.2. 4. Safe and effective use of medications and their side effects 4.1 to 4.6. Measurable Elements 1. There is an evidence that nurses who provide education have the subject knowledge. Patient’s and family’s language 1. Rehabilitation techniques 4. Patient’s physical and cognitive limitation 1.4. Managing patient when bed or space or facilities is not available st Standard II: Emergency Patients .3.4. Clinical services available 1. Pain management 4. Criteria for admitting patient or registering out patient 1. adequate time and communication skills to do so. The written policies and processes on patient access to care are evident which include but are not limited on the following: 1. The appropriate structure. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. When appropriate. 5.2. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs.5) are available. 6. Standards on Access and Continuity of Care Standard I: Access to Care In diverse health care setting.6.5.4. it is evident that the patient and family are educated on topics considered high risk to patients: 4. the Nursing Services Department has established policies and processes on patient access to care aligned with the organization.7. Holding area for patient on observation 126.96.36.199. Preventing interactions between prescribed medications and other medications (over the counter) and food 4.5. Education resources are available and organized in an efficient and effective manner. Process for admitting patient or registering out patient 1. 3.3. Treatment and diagnostic procedures IV.1. 2. Measurable Elements 1. Patient’s and family’s motivations and emotional barriers 1.
Proposed plan of care 2. 2. 2. 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. cultural. rehabilitative and palliative services and prioritizes these according to the patient’s health condition. Standard V: Continuity of Care In diverse health care setting. curative. 4. Measurable Elements 1. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training. Measurable Elements 1. Sufficient information to make knowledgeable decision and 2.4. . There is an evidence that staff who responded to emergency patients underwent the necessary training. curative. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. There is an evidence that patients with immediate needs/care are assessed.2.5. Limit or overcome barriers such as language.1. There is an evidence that nurse screening assessment focuses on preventive. It is evident that criteria is physiologic-based and developed by appropriate individuals. 3. Measurable Elements 1.The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. prioritized and received the necessary care as quickly as possible according to established physiologically based criteria. It is evident that patients admitted and or transferred to intensive and specialized areas/units meet the established criteria and are documented in the patient record. physical. 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 outcome of care 2. Standard III: Admitted Patients or In-Patients The needs of in-patients for preventive.Expected cost of care 2.3. 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. 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.
Other health care settings 2. Condition of patient at the time of discharge 6. There are criteria that determine patients readiness to be discharged.4. procedures and guidelines regarding the transfer of patient within and outside of the organization. Nursing ward services to diagnostic services 1.2. Significant physical and other findings 6. 5. and health professionals in the community.3. procedures and guidelines on patient’s discharge. Measurable Elements 1. referral and follow-up congruent with those of the organization. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. out on pass.Follow-up instruction in an understandable form and manner •Activity •Diet •Next medical consultation •Urgent care indicators 6. 4. 188.8.131.52.Nursing ward services to surgical and non surgical services 1.9. .3. There is a process on out on pass patients for a defined period of time. There is a referral system of patients for transfer to other organization. there is a qualified individual. Emergency services to nursing ward admission 1.5. Standard VII: Transfer of Patient The Nursing Services Department has established policies. referral and follow-up congruent with those of the organization. Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge.6.Measurable Elements 1. There are written policies. health organizations or agency.Nursing ward services to intensive or special services 1.8. Standard VI: Discharge. 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. Reason for admission 6. Medications to be taken at home 6. Out on Pass. Significant diagnosis and co-morbidities 6. Diagnostic and therapeutic procedures performed 6.1. Between nursing units or clinical departments 1. 3. 6.1.7. Out patient care programs 1. 3. Medications and treatments 6. Continuity of care and coordination of services are evident throughout all phases of care. 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: 6.4.6. identified as responsible for patient care and documented in the patient record. out on pass. Referral for support services to either health care providers. During all phases of care.
1. 2.3. Situation when transfer is not possible is stated. if any 1.9. gender. Patient’s transfer is documented. Registration number and or Admission number 1.6. age.7.1. Responsible health care provider during the patient’s transfer is identified. Language spoken 1. Measurable Elements . Summary of patient’s clinical condition. 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. care facility 1.2. Transfer is based on the patient’s needs for continuity of care.There is a written policy. Formal and informal arrangements are apparent.2. 2. Standards on Nursing Documentation Standard I: Structural Data applicable forms which include but are not limited on the following: 1. Mode of admission/transport/discharge 1.6. stretcher 1. Religion 1.7. 2.5. Date and time of admission and discharge 1. wheelchair. Safe and quality medical transport services within and outside of the organization are provided. 2. interventions (medical and nursing) and continuous care rendered are written. 2. Advance directive 1.4. Attending physician and referring physician. civil status 1.3. Admitted from: home.1. V.Measurable Elements 1. Transfer of responsibility to another health provider or health care setting is evident. Patient’s addressograph – name. 2. 2.4.The guidelines and procedures include but are not limited on the following: 2. 184.108.40.206.8. procedure and guidelines on transfer of patient within and outside of the organization. transferring hospital.4.4. Admitted via: ambulatory.
There is relevant/essential.1. There is an accurate and complete documentation of patients’ structural data in all nursing and 1.2. accurate and complete nursing documentation of patients’ clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following: 1. Measurable Elements 1. Health history Standard II: Governance Responsibility and Accountability . professional standards and institutional requirements.The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. Physical examination (head-to-toe) 1.
Pharmacological management 1. Psychological.Actual and potential health problems and needs 1. The Nursing Services governance structure depicts decentralization or unit-based wherein decisionmaking prevails to support and promote patient safety and quality improvement.10. Standards on Governance and Direction Standard I: Governance Structure The Nursing Services Department has governance structure designed to delineate lines of relationship. Preferences and idiosyncrasies ADMINISTRATION & MANAGEMENT I.Nursing interventions 1.Patients’ response and outcome 1.Diagnostic and therapeutic interventions 1. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.1. authority.Health teachings – patient and family 1. 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.8. The Nursing Services governance structure is described in written documents with the approval of proper authority. 2. 3.5. spiritual and economic evaluation 1. Measurable Elements 220.127.116.11. The Nursing Services governance structure and processes support professional communication.6. social.3. 4.
3. Standard III: Direction-Setting The Nursing Services Department has an established vision. managers. The governance responsibility and accountability are described in organization’s by-laws. 2. job description and other similar documents. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name. 4. core values and quality objectives congruent with that of the institution and the Nursing profession. reliable. core values and quality objectives congruent with that of the institution and the Nursing profession. Those responsible for governance appoint the Nursing Services Administrator.The governance responsibility and accountability are described in a written document to guide how they are to be carried out. The vision. measurable. philosophy. attainable. 2. primarily sets its direction by formulating its vision. mission. Measurable Elements 1. philosophy. philosophy and core values are written ( specific. Standard II: Governance Responsibility and Accountability . Measurable Elements 1. There is a written document that describes how the performances of the governing entity are appraised by specific criteria. mission. professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department. Those responsible for the Nursing Services Department governance. mission.
3. ethical and recorded ). Those responsible for governance have established current financial plans and allocation of resources . resources required and contingencies. widely disseminated.time bound. Measurable Elements 1. 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. timeframe. The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan. Measurable Elements 1. updated. Standard IV: Strategic & Operational Plans based on the needs of the Nursing Services Department. reviewed. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. 2. interpreted and operationalized. nursing manpower and unit operation of responsibility areas. Those in the managerial and clinical levels translate the overall Nursing Services Department’ strategic and management plans into action which include: the management of patient care. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives. action plan/activities.
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. rules and regulations. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. Those responsible for governance ensure compliance with the applicable statutory laws. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting. 3. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices. materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used. and conforms with the applicable statutory laws. Standard VI: Policies & Procedures Development The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration. 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. Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care. regulations and standards. 2. Measurable Elements 1. Measurable Elements 1. 4. The medical supplies. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers. 2. 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. Each Nursing Unit has an individual budget plan periodically monitored for variances.2. 3. .
There are Resource Management presence of Standard I: evidences Administrator of that the Nursing Services Nursing Service The Nursing Administra Services Department tor is is administered by a qualified qualified nursing to the administrator position pertinent to based on licensure. RA 9173 appropriate education. and other experience and criteria set demonstrable proven by the ability in nursing organizatio practice and n/institutio administration. II. and 1.administration courses at the graduate level. Standards on Human 1.1 accountable for the Qualificatio operation of the entire ns Nursing Services of the of organization/instituti on.1. n such as: fully responsible and 1. Be a member of good standing of the accredited professional organization of nurses. Nursing Measurable Elements Service Admini strators : .4.
Poss ess a degr ee of bach elor of Scien ce in Nursi ng. 1.A person occupy ing supervi sory or manage rial positio ns requirin g knowle dge of nursing must: 1. 1.1.1. with a least nine ( 9) unit s in man age ment and . 1.3. Be a regist ered nur se in the Philippi nes. Have at least two (2) years experie nce i n gener al nursi ng servi ce adminis tratio n.2.1.
in addition to the foregoing qualificatio ns.1. That for chief nurses in . At least five (5) years of experience in a supervisory or management p o s it i o n i n n u r s i n g 1. . 1. (1.3. possess: 1.1. A master’s degree major in nursing. the maximu m academic qualificati ons and experienc es for a chief nurse shall be as specified in subsectio ns (1.2. a n d 1. and (1. 1. That for primary hospitals .1.).1).2.1.3) of the above.A person occupying the position of chief nurse of director of nursing service shall.18.104.22.168.
those who have a master’s degree in public health/com munity health nursing shall be given priority.the public health agencies. 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. priority shall be given to those who have finished a master’s degree in nursing and the completio n of the General Staff Course (GSC). Standard II Staffing Plan : . That for chief nurses in military hospitals. 1.5. 2.
selection. 2. Those responsible for Nursing Services governance develop a staffing plan that identify the number. work experience) and other pertinent requirements. level and modality of care. skills and experience) of Nursing Services staff. education. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. patients’ mix. education. Standard III: Recruitment. patients’ needs and applicant qualification. reviewed and updated on an ongoing basis. training and work experiences of nursing personnel are documented and updated. Those responsible for Nursing Services governance consider the organization’s mission. 3. 3. staff and skills mix and other factors affecting the projection of staffing needs. Measurable Elements 1. reviewed and updated on an ongoing basis. There is evidence of standardized procedure to gather the credentials of all nursing staff.The Nursing Services Department has a staffing plan that identify the number. Those responsible for Nursing Services governance develop an effective process for gathering. verifying and evaluating the nursing staff credentials. Staff recruitment. hiring. Measurable Elements 1. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment. type of services. selection. appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures. . 3. 2. Standard IV: Credentialing The Nursing Services Department has an effective process for gathering. training. Hiring and Appointment The Nursing Services Department has an established system and processes for recruitment. hiring. There are legitimate and legitimized processes to recruit. type and desired qualification (education. Selection. selection. Measurable Elements 1. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services. 2. hiring and appointment are based on institutional. type and desired qualification of nursing services staff which is written. hire and appoint nursing services personnel and are uniformly implemented. verifying and evaluating the nursing staff credentials (licensure. select. The licensure. 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.
Measurable Elements 1. 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 evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary. which specifies duties and responsibilities based on established standards of performance.2. Standard VI: Staff Job Description The Nursing Services Department has job description for each position classification of Nursing personnel. There is a written Job Description for each position classification of Nursing Services personnel which . 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. 3. available resources and staff competencies. Measurable Elements 1. 2. Staff placement/assi gnment is based on patient needs.
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. There is evidence of staff development programs for all nursing personnel .1. Duties and responsibilities 1.3.2. Measurable Elements 1. 2.4. Functional relationship 1. Accountability 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.
Orientatio n program for newly hired and promoted staff. staff and property. training and opportunitie s for professional advanceme nt of staff member to enhance their knowledge and skills.throughout the year which include: a. Continuing education. c. Career counseling and career advanceme nt/ladder. Safety program to protect the patient. Resources are available to implement the staff development program such as: . d. 3. to the organizatio n department /unit to which they are assigned as well as their specific job responsibili ties. b.
Safety and Security •There is an existing provision for the identification of patient and their families. plan and budget for upgrading or replacing key components based on facility inspection findings. chemotherapeutic agents.6. Title of the program 5. Effectiveness of the program 5.4. 5. Records of staff development program are maintained which include: 5. tampering. Measurable Elements 1. Audiovisual equipment 22.214.171.124. Program design and content 5. Policies and procedures on continuing education staff attendance to staff development programs are evident. implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following: 1.3. staff and others. radio-active materials and waste.3. List of attendees/participants III. Measurable Elements 1. . Space and facilities 3. the Nursing Services Department provides a safe. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement.g.g. For efficient and effective delivery of nursing care and services. Standard II Environmental Safety : The Nursing Services Department actively participates in the planning.2. regulations and other requirements that are applicable. Clinical and clerical staff 3. Ther e is a wr itten and up-to-date plan. visitors. Those responsible for governance. Standards on Facility Management & Environment Safety Standard I Facility Planning : 2. chemicals. functional and supportive facility to patients and their families. •Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use.5.4. staff and visitors aligned with that of the organization’s master plan. (e. Those responsible for governance comply with relevant laws. Hazardous Materials and Waste •There is a current list of hazardous materials and waste to safely control them (e. Objectives of the program 5.3. 3. Educational resources 3.1.2. Medication Room) 1. Resource speakers 4.1. Evaluation of the attendees 5. destruction or loss. implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment.
Fire Safety waste). and that E EThere Documentation and reporting system are are infection surveillance. procedures and guidelines on infection control are implemented. processes in a continuous storage. : 1. electrical failure or interruption and medical gases unavailability. 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. • prevention and control programsinvestigation of spills.4.7. and recall system. and medical gases are available 24 hours a day. 1.hazardous gases and vapors. infectious institutional emergencies. inventory and 1.6. hazardous materials and wastes. E EThere is an evidenceis an fire safety plan and program of the •There that existing written organization/institution is implemented on handing. Utilities •Potable water. •Monitoring of utilities is evident for . •Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement. electrical power.and comprehensive manner to all patient care and staff work areas. preventive maintenance. Infection Control disposal of hazardous materials E EThere is evidencewaste. and disasters.policies. Standard III Staff Education 1. inventory. seven (7) days a week. use. •A written emergency processes is in place in the event of water interruption or contamination. regular inspection. labeling. to identify and reduce the risks of acquiring and transmitting infections among patients and nursing in place for E EThere exposures and that the nursing staffto is evidence other accidents related is provided with education on infection control practices. epidemics.3.
purposes of planning and improvement. Emergencies •An emergency management plan and processes are evident to likely community/ . 1.5.
There is an evidence that the staff can describe andService Philosophy. procedures and guidelines on patient clinical record. Vision. in-patient or out-patient available 1. to operate E medical equipment appropriate to their job Activities description. Circular. : : Measurable Elements 1.3. Guidelines. 1. There are written policies.3. programs. procedures. Clinical record for every patient assessed or •Patient/nursing care services treated. 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. 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.clinical staff) VI. •Health programs •Process to access care Measurable Elements 1. Nursing Personnel E ENursing endorsement in between work shifts 1. E ENursing 2. Patients and Families 1. Core Values demonstrate their role in the aforementioned safety Procedures. Mission.Community The Nursing Services Department has established •Patient/nursing care services policies.2.E EEducational materials and methods in an understandable format and language 1. nursing personnel and other health professionals throughout the organization. to patients and their families. There is efficient and effective system of communication that exist which include but are not limited on the following: 1. Security of record •Alternative sources of care and services .2.1. Standards 3. There is an evidence of staff training EMemorandum. Other Health Professionals (clinical and non. Directives. E EPolicies. There is an evidence of staff education and training E ENursing on facility management and environmental safetydocumentation E EReferral programs.4.1.
6. 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.Manuals of the Organization •Quality System •Infection Control •Emergency Preparedness •Employees’ Manual •Others 2. Retention of obsolete policies and procedures 2. Census of Patients and Diseases 1.6.11.Review and approval of all policies and procedures before implementation 2.2. References originating outside the organization 2.7. Measurable Elements 1. Guidelines 1. authorized person) V.10.Minutes of Meeting.Budget Plan 1. Use and monitoring of standardized abbreviations.1. Staff Development Programs 1.3. Identification of charges in policy and procedures 2.4.Quality Improvement Program and other Projects 1.6. 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. Process and frequency of review and continued approval of policies and procedures 2. date of issue. Staffing Pattern 1. Organization and Nursing Services Department Policies.12.5.Master Staffing Plan 1. procedure codes and definitions 1.8. Bed Capacity and Occupancy Rate 1. symbols. Measurable Elements .4. Tracking of policy and procedures in circulation (e.3.5.7. Data Integrity •Protection from tampering 1.2. Nursing and the Organization 1.g.9.• Protection from loss and destruction and unauthorized access and use 1.4. Standards 1. Committees.5. Procedures. 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.1. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following: 2. Nursing Services Department 1. title. Control that only current policy and procedures are implemented 2.
1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning. 5. Nursing documentation 1.1. Th er e i s an e v i de n c e t h at t h e qu a li t y improvement/processes and safety programs are approved by governance. 3. Prevention and control measures aligned with International Patient Safety Goals. high risk and problemprone processes. processes and results and data are aggregated. Intravenous fluids 1.6.2. reporting (needle stick injury. surveillance. There is an established reporting system on the quality and safety programs to governance. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice. 3 . There is a training program for staff consistent with their role in quality improvement and patient safety program. 4. monitoring.8. hand hygiene and barrier technique. clinical pathway) 2. (e. guidelines.9. Medication error 1. scientific literature.5. 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. Clinical research 1. Infection control. (Isolation Procedure) The Nursing Services Department has priority quality programs to reduce high volume. 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. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.7.3. There is a clinical monitoring that exists but is not limited on the following: 1. Total parenteral nutrition 1. .g. 6. body fluids and waste segregation/disposal) 1. clinical standards. 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. Analysis & Implementation : The Nursing Services Department has established key indicators to monitor the clinical and managerial structure. Medication safety. implemented and monitored for consistent use and effectiveness. 2. Measurable Elements 1. Surgical safety (sterilization/disinfection) 1. Measurable Elements 1.4. Blood and blood products 1. Standard III Quality Monitoring. analyzed and transformed to useful information. Standard II Quality Programs : and other relevant evidence – based information. analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs.
that includes actions for improvement or changes are planned. Credentialing – is the process of obtaining. the procedures performed. and other specific . Emergency Kart contents) GLOSSARY Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization. level of medical. ulation and those in governance and actions taken. verifying. the patient’s condition on discharge. tested and implemented. the treatment rendered. It includes the role of management to produce and control the use of data and information in work activities. psychological. or nursing care. 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. demonstrate that the improvements are effective and sustained. and assessing the qualifications of a health care practitioner like the nursing personnel. elements of care.g. if any supplies essential to most patient needs (e. Discharge Summary – is a section of patient record that summarizes the reasons for admittance. and information services. Communication Management – is the creation. Clinical Pathways – is an agreed-upon treatment regime or improvement are appropriate to the care. This applies within an organization or across multiple organizations.hat exists but is not limited on the following: iagnoses d complaints. information technology. use. or spiritual and social care or service. information resources management. scope and severity of the problems. the significant findings. Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting.
This includes ambulatory care centers. Other names for this group include “board. follow –up.” “board of commissioners. Informed Consent – is an agreement or permission accompanied by full information on the nature. or process. systems. home care organizations. nurse.” “board of trustees. End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment.” and “governing body.” board of governors. It is also known as a “health care institution. behavioral/mental health institutions. dentist. over time.” Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. and alternatives of a medical procedure or treatment before the . hospitals. and providing for organization management and planning. or allied health professionals. Indicator – is a measure of the performance of functions. Governance – refers to the individual(s).” Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. Health care professionals are often licensed by a government agency or certified by a professional organization. group or agency that have ultimate authority and responsibility for establishing policy. maintaining quality of care. laboratories and long term organizations. risks. medications). and his/her life expectancy is estimated to be within days or months. This includes a physician.instructions given to the patient or family (for example.
Patient Record/Clinical Record – is a written account of a variety of patient health information.Robbins. applicable licensure. outlines the criteria for ending intervention. th Edition. The plan of care may include prevention. such as assessment findings. practice guidelines. documents treatment goals and objectives. treatment. or certification. clinical paths or a combination of these. S. This record is created by nurses. The format of the plan in some organizations may be guided by specific policies and procedures. and rehabilitation. designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. In-Service Education – is an organized education. Qualification is determined by the following: education. usually provided in the workplace. experience. care. . 7 Pearson Education South Asia PTE LTD. law or regulation. and documents the individual’s progress in meeting specified goals and objectives. physician or other health care professional begins the procedure or treatment. protocols. training. Plan of Care – is a plan that identifies the patient’s care needs. registration. habilitation. lists the strategy to meet those needs. Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness. treatment details. Coulter M (2004). Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. physicians and other health care professionals involved in the care of patients. It is based on data gathered during patient assessment. competence. progress notes and discharge summary. Management.
Republic of the Philippines. Wright (2004). Philippines. Inc. Gerhart. Inc. Inc. 3 rd Edition Printed in USA 54321 Joint Commission International (2004). Accreditation Standards for Hospitals. treatment. Edition Printed in USA 54321 Noe. or process that must be in place for escribe the responsibilities for which t to receive. Credentialing. Fundamental of Human Resource Management. and other persons. including health care providers. Edition Printed in USA 54321 Joint Commission International (2004).opulations increase the likelihood of environment are reduced for a patient desired health outcomes and are consistent with current professional knowledge. and Philippine Nurses Association. . and service. Standards of Safe Nursing Practice Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). Human Resources for Hospitals. Inc. Metro Manila ctures. McGraw-Hill Co. 1 st Edition Joint Commission International (2008). The Administration of Hospital Nursing Services in Philippine Department of Health. (2001) Standards of Nursing Services Association of Nursing Service Administrators of the Philippines. REFERENCES an organization to provide safe and high-quality care. New York Republic Act 9173 or The Philippine Nursing Act of 1991. (1999). Association of Nursing Service Administrators of the nursing practitioners are accountable. Hollenback.
Nursing Administration Handbook. Guide to Nursing Management and Leadership. 7 Pearson Education South Asia PTE LTD. Nurse’s Handbook of Health Assessment. Lippincott Williams & Wilkins th .Robbins. Coulter M (2004). J (2006). 5 Edition.M (2004). S. Aspen Publication Tomey A. Management. th Editi Rowland H & Rowland B (1980). 7 th Edition Weber.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.