STANDARDS OF NURSING SERVICES

Association of Nursing Service Administrators of the Philippines, Inc.

(ANSAP)

Committee on Nursing Practice

2008 Edition

All rights reserved. All works herein are properties of ANSAP and no part of this book may be copied, reproduced or published in any form without the proper consent of the authors and publishers.

STANDARDS OF NURSING SERVICES

FOREWORD

This publication is designed to provide nursing administration a guide reference in managing nursing services. It also reflects the ANSAP’s deep commitment in improving the quality of patient care and management of nursing services in the Philippines.

The development was actively participated by the Board of Nursing (PRC-BON) and the ANSAP’s Board of Directors and validated by the Chief Nurses/Nursing Directors who are also members of ANSAP. The initial draft was eventually reviewed and discussed by opinion leaders in focus group of experts. The final blueprint was presented to public hearing attended by key stakeholders around the country.

This edition contains a complete set of standards presented in two major components namely; the Clinical and Administration management. Each component has five 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.

TABLE OF CONTENTS

• Introduction• Clinical Services

I. Standards on Assessment of CareStandard I. Assessment Process

Standard II. Assessment Scope and Content

II. Standards on Care of PatientStandard I. Care ProcessStandard II. Care PlanStandard III. Implementation of CareStandard IV. Evaluation of CareStandard V. Pain ManagementStandard VI. Medication ManagementStandard VII. End-of-Life CareStandard VIII. Patient and Family Rights

III. Standards on Patient and Family EducationStandard I. Education AssessmentStandard II. Education Plan and Programs

IV. Standards on Access and Continuity of CareStandard I. Access to CareStandard II. Emergency PatientsStandard III. Admitted Patients or In-PatientsStandard IV. Intensive and Specialized Services

Standard V. Continuity of CareStandard VI. Discharge, Out on Pass, Referral and Follow-up

Standard VII. Transfer of Patient

V. Standards on Nursing DocumentationStandard I. Structural DataStandard II. Clinical Data

• Administration and Management

I. Standards on Governance and DirectionStandard I. Governance StructureStandard II. Governance Responsibility and Accountability

Standard III. Direction-SettingStandard IV. Strategic and Operational PlansStandard V. Financial Plan and Resource Allocation

Standard VI. Policies and Procedures Development

Standard VII. Ethico – Moral and Legal Accountabilities

Standard VIII. Professional and Organizational Involvement

II. Standards on Human Resource ManagementStandard I. Administrator of Nursing ServicesStandard II. Staffing PlanStandard III. Recruitments, Selection, Hiring and Appointment

Standard IV. CredentialingStandard V. Staff PlacementStandard VI. Staff Job DescriptionStandard V. Staff Development

III. Standards on Facility Management and Environment Safety

Standard I. Facility PlanningStandard II. Environmental SafetyStandard III. Staff Education

IV. Standards on Communication ManagementStandard I. Communication of InformationStandard II. Patient Clinical RecordStandard III. Administrative Record

V. Standards on Quality ImprovementStandard I. Leadership and Staff EducationStandard II. Quality ProgramsStandard III. Quality Monitoring, Analysis and Implementation

INTRODUCTION

This manual is designed to assist health organizations or hospitals with the significant standards necessary to deliver quality nursing service to our clients. To achieve this, this designed manual has two components; Clinical and Administration and Management.

The first part is Clinical Services. This component focuses on defining what the standards are in the clinical setting. Utilizing nursing process – there are five identified standards to wit:

I. Standards on Assessment of Care. Classified under are two criteria which include the process and scope and content of assessment.

II. Standards on Care of Patient. There are seven (7) identified criteria that identify care process, care plan, implementation of care and evaluation of care rendered. Included 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.

IV. Standards on Access and Continuity of Care. 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.

V. Standards on Nursing Documentation. There are two identified criteria under this component, which include documentation of significant data both structure, and clinical based on applicable laws and regulations, professional standards and institutional requirements.

The second part is the Administration and Management. This concerns managing the nursing services in the hospital. There are five (5) standards identified:

I. Standards on Governance and Direction. There are seven (7) criteria included. This chapter recommends the need for organizational structure which will delineate responsibility, accountability and authority of nursing administration. These focus also on planning, direction, organization and controlling functions of the nursing service administration and their relationship with other services.

II. Standards on Human Resource Management. This part contains five (5) criteria which help the nursing administrators in placing the right person to do the right job through identification of the job requirements and qualifications. It also includes staffing modalities depending on the type of services.

III. Standards on Facility Management and Environmental Safety. This standard contains three (3) criteria and covers environmental safety

needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles.

IV. Standards on Communication Management. Three (3) criteria are identified focusing on the patient’s record, administration record and communication of information. It also enables the chief nurses/administrator to develop a specific hospital system which is efficient and effective.

V. Standards on Quality Improvement. This standard has three (3) criteria which address the need to institutionalize 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.

CLINICAL SERVICES

I. Standards on Assessment of Care

Standard I: Assessment Process

The nurse identifies the health care needs of each patient based on an established assessment process and within the prescribed timeframe.

Measurable Elements

1. There is an evidence of initial and completion of nursing assessment on the health care needs of each patient within the:1.1.1st 24 hours of admission as an in-patient or

earlier as indicated by the patient’s condition or institutional policy.

1.2.1st 2 hours of consultation as an outpatient or earlier as indicated by patient’s condition or institutional policy.

2. There is an evidence of patient’s reassessment throughout the care process to determine response to intervention at interval appropriate to patient’s condition, plan of care, individual needs or according to institutional policies and procedures (e.g. Pain is assessed every 4 hours and as necessary as part of the vital signs monitoring).

3. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patient’s assessment data and information.

4. Those responsible for direct nursing care prioritize patients’ needs based on assessment results.

5. 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 decision-making about the priority needs to be met.

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.

Measurable Elements

1. There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following:1.1. Psychological

• Knowledge level• Language spoken• Barriers to learning

1.2. Physical• Neurological assessment• Cardiovascular assessment• Respiratory assessment• Gastrointestinal assessment• Genitourinary assessment• Musculoskeletal assessment• Intergumentary assessment

• Sensory assessment1.3. Social

• Cultural concerns1.4. Spiritual

• Religion1.5. Economic factor

• Financial barrier

1.6. Health history• Developmental history (for pediatrics)• Family history• Medications taken• Allergies

1.7. Vital signs1.8. Pain assessment1.9. Nutritional status, needs and risks1.10.Preference and idiosyncrasies1.11.Discharge plan

• Place: home, extended, skilled care facility

• Individual who will accompany the patient home (name, address, telephone number, relationship)

2. There is an established screening criteria according to patients’ functional capacity and needs like:2.1. Nutritional – Metabolic Pattern2.2. Elimination Pattern2.3. Activity – Exercise Pattern2.4. Sleep – Rest Pattern2.5. Sexuality – Reproductive Pattern2.6. Sensory – Perceptual Pattern2.7. Cognitive Pattern2.8. Role – Relationship Pattern2.9. Self – Concept Pattern2.10.Coping – Stress Tolerance Pattern

2.11.Value – Belief Pattern3. Other pertinent data are collected using the

appropriate assessment, technique and instruments.

4. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care.

5. 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:5.1. Age5.2. Lack of mobility5.3. Continuing medical and nursing needs5.4. Assistance with activities of daily living5.5. Referral for continuity of care as necessary

II. 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.

Measurable Elements

1. There are existing policies and procedures on care process developed by those responsible for governance which include but are not limited on the following:

• Critically-ill• Mentally disadvantaged• Under anesthesia

1.1. Care of emergency patients (including use of resuscitation equipment)

1.2. Care of patient on life support (e.g. ventilatory equipment)

1.3. Care of patient on dialysis (hemodialysis, peritoneal dialysis)

1.4. Care of patients at risk:• Neonates• Children• Elderly• Disabled

1.5. Care of comatose patient1.6. Care of patient with communicable diseases1.7. Care of patient in restraint1.8. Care of patient on chemotherapy1.9. Care of immune - suppressed patients1.10. Care of patient in pain1.11. Care of patient on nutritional therapy1.12. Care of patient receiving blood and blood

components1.13. Care of patient receiving medications with

narrow margin of safety1.14. Care of perioperative patient1.15. 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.

Measurable Elements

1. There is a written care plan on every patient cared of by the nurse based on patient’s initial assessment data within the 1st 24 hours of assessment or earlier.

2. There is an evidence that family and significant others are involved in the planning process.2.1. Patient participate in planning of care taking

into consideration the cultural, religious and other beliefs of patients. Example: Selection of food

3. The care plan reflects the related and relevant identified needs and problems of each patient cared for.

4. The care plan ensures that priorities of care are established.

5. The care plan is updated as appropriate based on the reassessment made.

6. The care plan is documented in the individual patient’s record to promote continuity of care.

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, prevention of illness, alleviation of suffering and restoration of health.

Measurable Elements

1. There is an evidence that nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment based on but are not limited on the following:

1.1. Scope of Nursing Practice as provided by law and all relevant legislations (e.g. The Philippine Nursing Act of 2002 or Republic Act 9173)

1.2. Standard of Care:• Acute and Critical Care Nursing Practice• Chronic Care Nursing Practice• Cardiovascular Nursing Practice• Perioperative Nursing Practice• Maternal and Child Nursing Practice• Psychiatric Nursing Practice• Emergency Nursing Practice• Renal Nursing Practice• Pediatric Nursing Practice• Oncology Nursing Practice• Geriatric Nursing Practice• Ethical and Legal Nursing Practice• Nursing Standard on Intravenous Therapy• Infection Control Nursing Practice

1.3. Evidence - based practice1.4. Ten (10) Golden Rules in Drug Administration1.5. Code of Ethics for Nurses1.6. Patient Bill of Rights

2. It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations.

Standard IV: Evaluation of Care

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. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in the individualized patient record.

2. There is an evidence that evaluation of care and patient outcome occurs within an appropriate time frame after the intervention (nursing or medical) is initiated.

3. There is an evidence that patient’s responses to interventions are documented.

4. The revision in care plan if any is reflected in the patient record.

Standard V: Pain Management

The Nursing Services Department has established pain management guidelines for nurses to appropriately assess, monitor, evaluate and manage patients in pain.

Measurable Elements

1. There is an existing pain management guideline for nurses to appropriately assess, monitor, evaluate and manage patients in pain.

2. There is evidence that patients receive care according to pain management guidelines.

3. There are existing education and training programs for nurses on pain management.

4. Processes to communicate with and evaluate patients and families about pain are evident.

Standard VI: Medication Management

The Nursing Services Department has established policies, procedures and guidelines on medication management for symptomatic, curative, preventive, and palliative treatment of patients’ diseases and for safe nursing practice.

Measurable Elements

1. There are written policies, procedures and guidelines on medication management which include but are not limited on the following:1.1. Carrying out physician’s medication order1.2. Transcribing and ordering1.3. Endorsing (especially high valuable drugs)1.4. Preparing 1.5. Labeling1.6. Administering (10 Golden Rules in Drug

Administration)1.7. Documenting1.8. Monitoring and Storage1.9. Emergency Drugs1.10.Regulated Drugs1.11.Medication Recall System (Expired or

Outdated Drugs) 1.12.Reporting on

• Medication effects and adverse effects• Medication error and near-miss

Standard VII: End-of-Life Care

The nurse provides an end-of-life care to facilitate a dignified and peaceful closure of life for patients through physiological, psychological, social and spiritual care taking into consideration the cultural diversities in beliefs and customs and optimize caring environment.

Measurable Elements

1. Respect for patient’s values, religion and cultural preferences and practices is evident.1.1. Pastoral services are provided based on the

spiritual beliefs of the patient and family.1.2. The patient’s right of self-determination and

choices are respected and accommodated.1.3. Advance directives Do Not Resuscitate, Waiver,

Living will if any, are respected.1.4. Patient and family choices to donate organs and

other tissue are supported through provision of relevant information. In accordance to statutory laws, rules and regulations.

2. Assessment, appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re-assessment are evident.2.1. Pain assessment, intervention and evaluation,

are monitored and recorded.2.2. Personal hygiene is rendered based on patient’s

need.

2.3. Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration.

2.4. Interventions address patient and family’s psychosocial, emotional, spiritual and cultural concerns.

3. A place is designated for the patient’s family to stay.4. The patient and family are involved in care

management and decision.

Standard VIII: Patient and Family Rights

The Nursing Services Department has established policies, processes and guidelines that respect and support patient and family rights.

Measurable Elements

1. There are written policies, 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.

1.2. Respect for patient’s personal values and beliefs1.3. Respect the confidentiality of patient health

information1.4. Respect for patient’s need for privacy (e.g.

during treatment, procedure, physical examination, clinical interview, transport)

1.5. Protection of patient’s possessions from theft or loss

1.6. Protection of patient from physical assault (e.g. vulnerable patients are infants, children and elderly)

1.7. 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, treatment, outcome of care, 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. There is evidence that nurses are knowledgeable and supportive of patient and family rights.

III. 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.

Measurable Elements

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:1.1. Patient’s and family’s beliefs and values1.2. Patient’s and family’s literacy1.3. Patient’s and family’s educational level

1.4. Patient’s and family’s language1.5. Patient’s and family’s motivations and

emotional barriers1.6. Patient’s physical and cognitive limitation1.7. 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. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs.

2. The appropriate structure, methods and mechanism for education is afforded.

3. Education resources are available and organized in an efficient and effective manner.

4. When appropriate, it is evident that the patient and family are educated on topics considered high risk to patients:4.1. Safe and effective use of medications and their

side effects4.2. Preventing interactions between prescribed

medications and other medications (over the counter) and food

4.3. Safe and effective use of medical equipment4.4. Pain management4.5. Rehabilitation techniques4.6. Treatment and diagnostic procedures

5. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4.1 to 4.5) are available.

6. There is an evidence that nurses who provide education have the subject knowledge, adequate time and communication skills to do so.

IV. Standards on Access and Continuity of Care

Standard I: Access to Care

In diverse health care setting, the Nursing Services Department has established policies and processes on patient access to care aligned with the organization.

Measurable Elements

1. The written policies and processes on patient access to care are evident which include but are not limited on the following:1.1. Clinical services available1.2. Triage or screening

• There is evidence that triaging or screening is initiated at the point of 1st

contact with the patient1.3. Criteria for admitting patient or registering

out patient1.4. Process for admitting patient or registering

out patient1.5. Holding area for patient on observation1.6. Managing patient when bed or space or

facilities is not available

Standard II: Emergency Patients

The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse.

Measurable Elements

1. There is an evidence that patients with immediate needs/care are assessed, prioritized and received the necessary care as quickly as possible according to established physiologically based criteria.

2. There is an evidence that staff who responded to emergency patients underwent the necessary training.

Standard III: Admitted Patients or In-Patients

The needs of in-patients for preventive, 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.

Measurable Elements

1. There is an evidence that nurse screening assessment focuses on preventive, curative, rehabilitative and palliative services and prioritizes these according to the patient’s health condition.

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:

2.1. Proposed plan of care2.2. Expected outcome of care2.3. Expected cost of care2.4. Sufficient information to make knowledgeable

decision and 2.5. Limit or overcome barriers such as language,

cultural, physical, to access and in the delivery of care

Standard IV: Intensive and Specialized Services

The Nursing Services Department has established entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs congruent with those of the organization.

Measurable Elements

1. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs.

2. It is evident that criteria is physiologic-based and developed by appropriate individuals.

3. It is evident that patients admitted and or transferred to intensive and specialized areas/units meet the established criteria and are documented in the patient record.

4. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training.

Standard V: Continuity of Care

In diverse health care setting, the Nursing Services Department has established policies and processes on patient continuity of care aligned with those of the organization and coordinated among other health professionals.

Measurable Elements

1. 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:

1.1. Emergency services to nursing ward admission1.2. Nursing ward services to diagnostic services1.3. Nursing ward services to surgical and non-

surgical services1.4. Between nursing units or clinical departments1.5. Nursing ward services to intensive or special

services1.6. Out patient care programs1.7. Other health care settings

2. During all phases of care, there is a qualified individual, identified as responsible for patient care and documented in the patient record.

3. Continuity of care and coordination of services are evident throughout all phases of care.

Standard VI: Discharge, Out on Pass, Referral and Follow-up

The Nursing Services Department has established policies and processes and guidelines on patient’s discharge, out on pass, referral and follow-up congruent with those of the organization.

Measurable Elements

1. There are written policies, procedures and guidelines on patient’s discharge, out on pass, referral and follow-up congruent with those of the organization.

2. There are criteria that determine patients readiness to be discharged.

3. There is a process on out on pass patients for a defined period of time.

4. There is a referral system of patients for transfer to other organization.

5. The patient’s discharge summary is prepared by qualified individuals recognized by the organization.

6. A copy of patient’s discharge summary is placed in the patient record and another copy is given to the patient which include but are not limited on the following:6.1. Reason for admission6.2. Significant physical and other findings6.3. Significant diagnosis and co-morbidities 6.4. Diagnostic and therapeutic procedures

performed6.5. Medications and treatments6.6. Medications to be taken at home6.7. Condition of patient at the time of discharge6.8. Follow-up instruction in an understandable form

and manner• Activity• Diet• Next medical consultation• Urgent care indicators

6.9. Referral for support services to either health care providers, health organizations or agency, and health professionals in the community.

Standard VII: Transfer of Patient

The Nursing Services Department has established policies, procedures and guidelines regarding the transfer of patient within and outside of the organization.

Measurable Elements

1. There is a written policy, procedure and guidelines on transfer of patient within and outside of the organization.

2. The guidelines and procedures include but are not limited on the following:2.1. Transfer is based on the patient’s needs for

continuity of care.2.2. Transfer of responsibility to another health

provider or health care setting is evident.2.3. Responsible health care provider during the

patient’s transfer is identified.2.4. Formal and informal arrangements are apparent. 2.5. Summary of patient’s clinical condition,

interventions (medical and nursing) and continuous care rendered are written.

2.6. Situation when transfer is not possible is stated.2.7. Patient’s transfer is documented.2.8. Safe and quality medical transport services

within and outside of the organization are provided.

V. Standards on Nursing Documentation

Standard I: Structural Data

The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations, professional standards and institutional requirements.

Measurable Elements

1. There is an accurate and complete documentation of patients’ structural data in all nursing and

applicable forms which include but are not limited on the following:

1.1. Patient’s addressograph – name, age, gender, civil status

1.2. Registration number and or Admission number

1.3. Date and time of admission and discharge1.4. Mode of admission/transport/discharge

1.4.1. Admitted via: ambulatory, wheelchair, stretcher

1.4.2. Admitted from: home, transferring hospital, care facility

1.5. Attending physician and referring physician, if any

1.6. Religion1.7. Language spoken1.8. Advance directive1.9. 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. There is relevant/essential, accurate and complete nursing documentation of patients’ clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following:

1.1. Physical examination (head-to-toe)1.2. Health history

1.3. Psychological, social, spiritual and economic evaluation

1.4. Actual and potential health problems and needs

1.5. Diagnostic and therapeutic interventions1.6. Pharmacological management1.7. Nursing interventions1.8. Health teachings – patient and family1.9. Patients’ response and outcome1.10. Preferences and idiosyncrasies

ADMINISTRATION & MANAGEMENT

I. Standards on Governance and Direction

Standard I: Governance Structure

The Nursing Services Department has governance structure designed to delineate lines of relationship, authority, responsibility and accountability and the mechanisms for communication and coordination within the Nursing Services and other services/departments of the health care facility.

Measurable Elements

1. The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.

2. The Nursing Services governance structure is described in written documents with the approval of proper authority.

3. The Nursing Services governance structure depicts decentralization or unit-based wherein decision-making prevails to support and promote patient safety and quality improvement.

4. The Nursing Services governance structure and processes support professional communication, clinical planning and services and policy development.

Standard II: Governance Responsibility and Accountability

The governance responsibility and accountability are described in a written document to guide how they are to be carried out.

Measurable Elements

1. The governance responsibility and accountability are described in organization’s by-laws, job description and other similar documents.

2. Those responsible and accountable for governing and managing the Nursing Services Department are identified by position title and name.

3. Those responsible for governance appoint the Nursing Services Administrator, managers, professional technical staff and assistive nursing personnel to carry out the functions of the Nursing Services Department.

4. There is a written document that describes how the performances of the governing entity are appraised by specific criteria.

Standard III: Direction-Setting

The Nursing Services Department has an established vision, mission, philosophy, core values and quality objectives congruent with that of the institution and the Nursing profession.

Measurable Elements

1. Those responsible for the Nursing Services Department governance, primarily sets its direction by formulating its vision, mission, philosophy, core values and quality objectives congruent with that of the institution and the Nursing profession.

2. The vision, mission, philosophy and core values are written (specific, measurable, attainable, reliable,

time bound, ethical and recorded), reviewed, updated, widely disseminated, interpreted and operationalized.

Standard IV: Strategic & Operational Plans

The Nursing Services Department has documented strategic and operational plans consistent with the hospital wide quality plan.

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.

2. There is an existence of strategic and operational plans periodically set and reviewed which contains goals and objectives, action plan/activities, timeframe, resources required and contingencies.

3. 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, nursing manpower and unit operation of responsibility areas.

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. Those responsible for governance have established current financial plans and allocation of resources based on the needs of the Nursing Services Department.

2. The capital and operating budgets are implemented as approved by the authorized person/office and monitored based on responsibility accounting.

3. Each Nursing Unit has an individual budget plan periodically monitored for variances.

4. The medical supplies, materials and equipment recommended by professional organizations and authoritative sources are obtained and appropriately used.

Standard VI: Policies & Procedures Development

The policies and procedures of the Nursing Services Department that reflect Standards of Nursing Administration, Nursing Practice on Patient Care are developed and communicated to serve as operational guidelines.

Measurable Elements

1. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care.

2. 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.

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, and

conforms with the applicable statutory laws, rules and regulations.

Measurable Elements

1. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care.

2. Those responsible for governance ensure compliance with the applicable statutory laws, regulations and standards.

3. The Nursing Services Department has a written Code of Ethical Behavior which observes the rights and safety of patients and health care providers.

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.

Measurable Elements

1. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices, professional and interprofessional relationships and other related endeavors.

II. Standards on Human Resource Management

Standard I: Administrator of Nursing Services

The Nursing Services Department is administered by a qualified nursing administrator pertinent to licensure, appropriate education, experience and demonstrable proven ability in nursing practice and administration, fully responsible and accountable for the operation of the entire Nursing Services of the organization/institution.

Measurable Elements

1. There are presence of evidences that the Nursing Service Administrator is qualified to the position based on RA 9173 and other criteria set by the organization/institution such as:1.1 Qualifications of Nursing Service

Administrators: A person occupying supervisory or

managerial positions requiring knowledge of nursing must:1.1.1. Be a registered nurse in the

Philippines;1.1.2. Have at least two (2) years experience

in general nursing service administration;

1.1.3. Possess a degree of bachelor of Science in Nursing, with a least nine (9) units in management and

administration courses at the graduate level; and

1.1.4. Be a member of good standing of the accredited professional organization of nurses.

1.2. A person occupying the position of chief nurse of director of nursing service shall, in addition to the foregoing qualifications, possess:1.1.1. At least five (5) years of experience

in a supervisory or management position in nursing; and

1.1.2. A master’s degree major in nursing.1.3. That for primary hospitals, the maximum

academic qualifications and experiences for a chief nurse shall be as specified in subsections (1.1.1), (1.1.2.), and (1.1.3) of the above.

1.4. That for chief nurses in the public health agencies; those who have a master’s degree in public health/community health nursing shall be given priority.

1.5. That for chief nurses in military hospitals, priority shall be given to those who have finished a master’s degree in nursing and the completion of the General Staff Course (GSC).

2. Those responsible for the overall administration and management of Nursing Services is a member of the top Executive/Management Committee who participates in their regular meetings and provides advice and recommendations in relation to nursing practice.

Standard II: Staffing Plan

The Nursing Services Department has a staffing plan that identify the number, type and desired qualification of nursing services staff which is written, reviewed and updated on an ongoing basis.

Measurable Elements

1. Those responsible for Nursing Services governance develop a staffing plan that identify the number, type and desired qualification (education, skills and experience) of Nursing Services staff, reviewed and updated on an ongoing basis.

2. Those responsible for Nursing Services governance consider the organization’s mission, type of services, level and modality of care, patients’ mix, staff and skills mix and other factors affecting the projection of staffing needs.

3. The staffing plan is defined in writing and meets the needs of the patients/population served and scope of services.

Standard III: Recruitment, Selection, Hiring and Appointment

The Nursing Services Department has an established system and processes for recruitment, selection, hiring, appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures.

Measurable Elements

1. Those responsible for the Nursing Services governance actively participate/collaborate in the

development of system and processes for recruitment, selection, hiring, appointment and promotion of nursing service personnel in accordance with the statutory laws and regulations and the institutional policies and procedures.

2. There are legitimate and legitimized processes to recruit, select, hire and appoint nursing services personnel and are uniformly implemented.

3. Staff recruitment, selection, hiring and appointment are based on institutional, patients’ needs and applicant qualification.

Standard IV: Credentialing

The Nursing Services Department has an effective process for gathering, verifying and evaluating the nursing staff credentials.

Measurable Elements

1. Those responsible for Nursing Services governance develop an effective process for gathering, verifying and evaluating the nursing staff credentials (licensure, education, training, work experience) and other pertinent requirements.

2. There is evidence of standardized procedure to gather the credentials of all nursing staff.

3. The licensure, education, training and work experiences of nursing personnel are documented and updated.

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.

2. There are written core competencies required for every job position in the Nursing Services organization to ensure that the staff skills are consistent with the patients’ needs.

3. Staff placement/assignment is based on patient needs, available resources and staff competencies.

Standard VI: Staff Job Description

The Nursing Services Department has job description for each position classification of Nursing personnel, which specifies duties and responsibilities based on established standards of performance.

Measurable Elements

1. There is a written Job Description for each position classification of Nursing Services personnel which specifies:1.1. Duties and responsibilities1.2. Accountability1.3. Functional relationship1.4. Qualification and experience required

2. There is evidence that the Job Description of Nursing Services personnel is reviewed at least once every 3 years and revised when necessary.

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.

Measurable Elements

1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.

2. There is evidence of staff development programs for all nursing personnel throughout the year which include:a. Orientation program for newly hired and

promoted staff, to the organization department/unit to which they are assigned as well as their specific job responsibilities.

b. Safety program to protect the patient, staff and property.

c. Continuing education, training and opportunities for professional advancement of staff member to enhance their knowledge and skills.

d. Career counseling and career advancement/ladder.

3. Resources are available to implement the staff development program such as:

3.1. Space and facilities3.2. Educational resources3.3. Clinical and clerical staff3.4. Audiovisual equipment3.5. Resource speakers

4. Policies and procedures on continuing education staff attendance to staff development programs are evident.

5. Records of staff development program are maintained which include:5.1. Title of the program5.2. Objectives of the program5.3. Program design and content5.4. Evaluation of the attendees5.5. Effectiveness of the program5.6. List of attendees/participants

III. Standards on Facility Management & Environment Safety

Standard I: Facility Planning

For efficient and effective delivery of nursing care and services, the Nursing Services Department provides a safe, functional and supportive facility to patients and their families, staff and visitors aligned with that of the organization’s master plan.

Measurable Elements

1. Those responsible for governance comply with relevant laws, regulations and other requirements that are applicable.

2. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement.

3. Those responsible for governance, plan and budget for upgrading or replacing key components based on facility inspection findings.

Standard II: Environmental Safety

The Nursing Services Department actively participates in the planning, implementation and evaluation of hospital – wide programs to provide a safe and secure physical environment.

Measurable Elements

1. There is a written and up-to-date plan, implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following:1.1. Safety and Security

• There is an existing provision for the identification of patient and their families, visitors, staff and others.

• Monitoring mechanism of all risk areas is in place and kept secure to patient from unauthorized access or use, tampering, destruction or loss. (e.g. Medication Room)

1.2. Hazardous Materials and Waste• There is a current list of hazardous

materials and waste to safely control them (e.g. chemotherapeutic agents, chemicals, radio-active materials and waste,

hazardous gases and vapors, infectious waste).

• There is an existing written processes on handing, labeling, storage, use, inventory and disposal of hazardous materials and waste.

• Documentation and reporting system are in place for investigation of spills, exposures and other accidents related to hazardous materials and wastes.

1.3. Medical Equipment• There is an updated policy and processes

on medical equipment procurement, inventory, regular inspection, preventive maintenance, and recall system.

• Monitoring of equipment functionality and utilization is in place for purposes of planning and improvement.

1.4. Utilities• Potable water, electrical power, and

medical gases are available 24 hours a day, seven (7) days a week.

• A written emergency processes is in place in the event of water interruption or contamination, electrical failure or interruption and medical gases unavailability.

• Monitoring of utilities is evident for purposes of planning and improvement.

1.5. Emergencies• An emergency management plan and

processes are evident to likely community/

institutional emergencies, epidemics, and disasters.

1.6. Fire Safety• There is an evidence that fire safety plan

and program of the organization/institution is implemented in a continuous and comprehensive manner to all patient care and staff work areas.

1.7. Infection Control• There is evidence that policies, procedures

and guidelines on infection control are implemented.

• There are infection surveillance, prevention and control programs to identify and reduce the risks of acquiring and transmitting infections among patients and nursing staff.

• There is evidence that the nursing staff is provided with education on infection control practices.

Standard III: Staff Education

The Nursing Services Department ensures education and training of staff to effectively carry out their roles in creating a safe and sound patient and staff environment.

Measurable Elements

1. There is an evidence of staff education and training on facility management and environmental safety programs.

2. There is an evidence that the staff can describe and demonstrate their role in the aforementioned safety programs.

3. There is an evidence of staff training to operate medical equipment appropriate to their job description.

VI. Standards on Communication Management

Standard I: Communication of Information

The Nursing Services Department has efficient and effective system of communication with the community, to patients and their families, nursing personnel and other health professionals throughout the organization.

Measurable Elements

1. There is efficient and effective system of communication that exist which include but are not limited on the following:1.1. Community

• Patient/nursing care services• Health programs• Process to access care

1.2. Patients and Families• Patient health condition• Care provided to patient• Patient’s response to care• Patient/nursing care services available• Alternative sources of care and services• Process to access care

• Educational materials and methods in an understandable format and language

1.3. Nursing Personnel• Nursing endorsement in between work

shifts• Nursing documentation• Referral• Nursing Service Philosophy, Vision,

Mission, Core Values• Policies, Procedures, Guidelines,

Standards• Memorandum, Circular, Directives,

Activities

1.4. Other Health Professionals (clinical and non-clinical staff)

• Patient care and response to care (referral)• Patient clinical data (diagnostic

examinations and therapeutic procedures)• Circular

Standard II: Patient Clinical Record

The Nursing Services Department has established policies, procedures and guidelines on patient clinical record.

Measurable Elements

1. There are written policies, procedures, and guidelines on patient clinical record which include but are not limited on the following:1.1. Clinical record for every patient assessed or

treated, in-patient or out-patient1.2. Confidentiality of record1.3. Security of record

• Protection from loss and destruction and unauthorized access and use

1.4. Data Integrity• Protection from tampering

1.5. Use and monitoring of standardized abbreviations, symbols, procedure codes and definitions

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.

Measurable Elements

1. 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:1.1. Organization and Nursing Services Department

Policies, Procedures, Guidelines1.2. Standards1.3. Master Staffing Plan1.4. Staffing Pattern1.5. Census of Patients and Diseases1.6. Bed Capacity and Occupancy Rate1.7. Budget Plan1.8. Staff Development Programs1.9. Committees, Nursing and the Organization1.10.Minutes of Meeting, Nursing Services

Department

1.11.Quality Improvement Program and other Projects

1.12.Manuals of the Organization• Quality System• Infection Control• Emergency Preparedness• Employees’ Manual• Others

2. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following:2.1. Review and approval of all policies and

procedures before implementation2.2. Process and frequency of review and continued

approval of policies and procedures2.3. Control that only current policy and procedures

are implemented2.4. Identification of charges in policy and

procedures2.5. Retention of obsolete policies and procedures2.6. References originating outside the organization2.7. Tracking of policy and procedures in circulation

(e.g. title, date of issue, authorized person)

V. 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.

Measurable Elements

1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning, monitoring, analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs.

2. 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.

3. There is a training program for staff consistent with their role in quality improvement and patient safety program.

4. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.

5. There is an established reporting system on the quality and safety programs to governance.

6. 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

The Nursing Services Department has priority quality programs to reduce high volume, high risk and problem-prone processes.

Measurable Elements

1. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice, guidelines, clinical standards, scientific literature,

and other relevant evidence – based information. (e.g. Medication safety, clinical pathway)

2. There is an existing plan and program to reduce the risk of community/hospital acquired infectious for patients and health care associated infections for staff.

3. There is an evidence that the quality improvement/processes and safety programs are approved by governance, implemented and monitored for consistent use and effectiveness.

Standard III: Quality Monitoring, Analysis & Implementation

The Nursing Services Department has established key indicators to monitor the clinical and managerial structure, processes and results and data are aggregated, analyzed and transformed to useful information.

Measurable Elements

1. There is a clinical monitoring that exists but is not limited on the following:1.1. Clinical research1.2. Nursing documentation1.3. Medication error1.4. Intravenous fluids1.5. Blood and blood products1.6. Total parenteral nutrition1.7. Surgical safety (sterilization/disinfection)1.8. Infection control, surveillance, reporting (needle

stick injury, hand hygiene and barrier technique, body fluids and waste segregation/disposal)

1.9. Prevention and control measures aligned with International Patient Safety Goals. (Isolation Procedure)

2. There is a managerial monitoring that exists but is not limited on the following:2.1. Patient demographics and clinical diagnoses2.2. Patient and family expectations and complaints,

if any2.3. Availability of drugs and medical supplies

essential to most patient needs (e.g. Emergency Kart contents)

2.4. Financial budget2.5. Manpower utilization2.6. Staff expectations and satisfaction2.7. Incident reports and sentinel events2.8. Reports as required by law and regulation and

those in governance3. There is an evidence data analysis and actions taken.4. There is an evidence that actions for improvement

are appropriate to the care, scope and severity of the problems.

5. There is an evidence that the actions for improvement or changes are planned, tested and implemented.

6. There is a written available data to demonstrate that the improvements are effective and sustained.

GLOSSARY

Adverse Event – is an unanticipated or potentially dangerous occurrence in health care organization.

Clinical Pathways – is an agreed-upon treatment regime that includes elements of care.

Communication Management – is the creation, use, sharing and disposal of data or information for effective and efficient operation of organization activities. It includes the role of management to produce and control the use of data and information in work activities, information resources management, information technology, and information services.

Continuity of Care – is the matching of an individual’s ongoing needs with the appropriate care setting; level of medical, psychological, or nursing care; or spiritual and social care or service. This applies within an organization or across multiple organizations.

Credentialing – is the process of obtaining, verifying, and assessing the qualifications of a health care practitioner like the nursing personnel. The process determines if an individual can provide patient care services in or for a health care organization.

Discharge Summary – is a section of patient record that summarizes the reasons for admittance, the significant findings, the procedures performed, the treatment rendered, the patient’s condition on discharge, and other specific

instructions given to the patient or family (for example, follow –up, medications).End-of-Life Care – is the provision of care to the patient whose disease condition is not responsive to curative treatment, and his/her life expectancy is estimated to be within days or months.

Governance – refers to the individual(s), group or agency that have ultimate authority and responsibility for establishing policy, maintaining quality of care, and providing for organization management and planning. Other names for this group include “board,” “board of trustees,” board of governors,” “board of commissioners,” and “governing body.”

Health Care Organization – is a generic term used to describe many types of organizations that provide health care services. This includes ambulatory care centers, behavioral/mental health institutions, home care organizations, hospitals, laboratories and long term organizations. It is also known as a “health care institution.”

Health Care Professional – is any person who has completed a course of study and is skilled in a field of health. This includes a physician, dentist, nurse, or allied health professionals. Health care professionals are often licensed by a government agency or certified by a professional organization.

Indicator – is a measure of the performance of functions, systems, or process, over time.

Informed Consent – is an agreement or permission accompanied by full information on the nature, risks, and alternatives of a medical procedure or treatment before the

physician or other health care professional begins the procedure or treatment.

In-Service Education – is an organized education, usually provided in the workplace, designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines.

Palliative Services – are treatments and support services intended to alleviate pain and suffering rather than to cure illness.

Patient Record/Clinical Record – is a written account of a variety of patient health information, such as assessment findings, treatment details, progress notes and discharge summary. This record is created by nurses, 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, lists the strategy to meet those needs, documents treatment goals and objectives, outlines the criteria for ending intervention, and documents the individual’s progress in meeting specified goals and objectives. It is based on data gathered during patient assessment. The format of the plan in some organizations may be guided by specific policies and procedures, protocols, practice guidelines, clinical paths or a combination of these. The plan of care may include prevention, care, treatment, habilitation, and rehabilitation.

Qualified Individual – is an individual or staff member who can participate in one or all of the organization’s care activities or services. Qualification is determined by the following: education, training, experience, competence, applicable licensure, law or regulation, registration, or certification.

Quality of Care – is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Safety – is the degree to which the risk of an intervention and risk in the care environment are reduced for a patient and other persons, including health care providers.

Standard – is a statement that defines the performance expectations, structures, or process that must be in place for an organization to provide safe and high-quality care, treatment, and service.

Standard of Nursing Practice – is an authoritative statements that describe the responsibilities for which nursing practitioners are accountable.

Outcome Standards – Describes the basis level of care the patient can expect to receive.

REFERENCES

Association of Nursing Service Administrators of the Philippines, Inc. (2001) Standards of Nursing Services

Association of Nursing Service Administrators of the Philippines, Inc. and Philippine Nurses Association, Inc. (1999). Standards of Safe Nursing Practice

Committee on the Revision of the Hospital Nursing Service Administrative Manual (1990). The Administration of Hospital Nursing Services in Philippine Department of Health, 1st Edition

Joint Commission International (2008). Accreditation Standards for Hospitals, 3rd Edition Printed in USA 54321

Joint Commission International (2004). Credentialing, Edition Printed in USA 54321

Joint Commission International (2004). Human Resources for Hospitals, Edition Printed in USA 54321

Noe, Hollenback, Gerhart, Wright (2004). Fundamental of Human Resource Management, McGraw-Hill Co. Inc. New York

Republic Act 9173 or The Philippine Nursing Act of 1991, Republic of the Philippines, Metro Manila

Robbins, S. Coulter M (2004). Management, 7th Edition, Pearson Education South Asia PTE LTD.

Rowland H & Rowland B (1980). Nursing Administration Handbook, Aspen Publication

Tomey A.M (2004). Guide to Nursing Management and Leadership, 7th Edition

Weber, J (2006). Nurse’s Handbook of Health Assessment, 5th

Edition, Lippincott Williams & Wilkins