STANDARDS OF NURSING SERVICES

Association of Nursing Service Administrators of the hi!i""ines# Inc$ %ANSA & Committee on Nursing Practice '(() Edition

STANDARDS OF NURSING SERVICES

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.

FORE*ORD
This publication is designed to provide nursing administration a guide reference in managing nursing services. It also reflects the ANSAPs deep commitment in improving the quality of patient care and management of nursing services in the Philippines. The development was actively participated by the oard of Nursing !P"#$ %N& and the ANSAPs oard of 'irectors and validated by the #hief Nurses(Nursing 'irectors who are also members of ANSAP. The initial draft was eventually reviewed and discussed by opinion leaders in focus group of e)perts. The final blueprint was presented to public hearing attended by *ey sta*eholders around the country. This edition contains a complete set of standards presented in two ma+or components namely, the #linical and Administration management. -ach component has five standards. criteria and measurable elements necessary to help organi/ations 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 li*e 0oint #ommission International !0#I&. 1e view that standards are continuously a wor* in progress. 2ence. we welcome any comments and suggestions for improvement.
V.

TA+,E OF CONTENTS

Introduction C!inica! Services I. Standards on Assessment of Care Standard I. Assessment Process Standard II. II. Assessment Scope and #ontent

Standards on Care of Patient Standard I. #are Process Standard II. #are Plan Standard III. Implementation of #are Standard I3. -valuation of #are Standard 3. Pain 4anagement Standard 3I. 4edication 4anagement Standard 3II. -nd$of$5ife #are Standard 3III. Patient and 6amily "ights Standards on Patient and Family Education Standard I. -ducation Assessment Standard II. -ducation Plan and Programs Standards on Access and Continuity of Care Standard I. Access to #are Standard II. -mergency Patients Standard III. Admitted Patients or In$Patients Standard I3. Intensive and Speciali/ed Services Standard 3. Standard 3I. Standard 3II. #ontinuity of #are
'ischarge. %ut on Pass. "eferral and 6ollow$up

III.

IV.

Transfer of Patient

Standards on Nursing Documentation Standard I. Structural 'ata Standard II. #linical 'ata

Administration and -anagement I. Standards on overnance and !irection Standard I. 7overnance Structure Standard II. 7overnance "esponsibility and Accountability Standard III. 'irection$Setting Standard I3. Strategic and %perational Plans Standard 3. 6inancial Plan and "esource Allocation Standard 3I. Policies and Procedures 'evelopment Standard 3II. -thico 8 4oral and 5egal Accountabilities Standard 3III. Professional and %rgani/ational Involvement Standards on Human Resource Management Standard I. Administrator of Nursing Services Standard II. Staffing Plan Standard III. "ecruitments. Selection. 2iring and Appointment Standard I3. #redentialing Standard 3. Staff Placement Standard 3I. Staff 0ob 'escription Standard 3. Staff 'evelopment Standards on Facility Management and En ironment Safety Standard I. 6acility Planning Standard II. -nvironmental Safety Standard III. Staff -ducation Standards on Communication Management Standard I. #ommunication of Information Standard II. Patient #linical "ecord Standard III. Administrative "ecord Standards on !uality Im"ro ement Standard I. 5eadership and Staff -ducation Standard II. 9uality Programs Standard III. 9uality 4onitoring. Analysis and Implementation

INTRODUCTION
This manual is designed to assist health organi/ations or hospitals with the significant standards necessary to deliver quality nursing service to our clients. To achieve this. this designed manual has two components, #linical and Administration and 4anagement. The first part is #linical Services. This component focuses on defining what the standards are in the clinical setting. :tili/ing nursing process 8 there are five identified standards to wit;

II.

I.

Standards on Assessment of Care. #lassified under are two criteria which include the process and scope and content of assessment. Standards on Care of atient. There are seven !<& 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. Standards on atient and Fami!. Education has two criteria in which the nurses independent role in providing health education is hereby identified. Standards on Access and Continuit. of Care. There are seven !<& 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.

II.

III.

IV.

III.

V.

I3.

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

3.

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.

I3.

Standards on Communication -anagement. Three !>& criteria are identified focusing on the patients 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. Standards on 0ua!it. Im"rovement. This standard has three !>& criteria which address the need to institutionali/e continuous quality and performance improvement.

The second part is the Administration and 4anagement. This concerns managing the nursing services in the hospital. There are five !=& standards identified;

3.

I.

Standards on Governance and Direction. There are seven !<& criteria included. This chapter recommends the need for organi/ational structure which will delineate responsibility. accountability and authority of nursing administration. These focus also on planning. direction. organi/ation and controlling functions of the nursing service administration and their relationship with other services. Standards on /uman Resource -anagement. This part contains five !=& criteria which help the nursing administrators in placing the right person to do the right +ob through identification of the +ob requirements and qualifications. It also includes staffing modalities depending on the type of services. Standards on Faci!it. -anagement and Environmenta! Safet.. This standard contains three !>& criteria and covers environmental safety

-ach standard and criteria has identified measurable elements intended to provide clarity to the standards and to help organi/ations develop their own policies and procedures according to the standards.

II.

III.

C,INICA, 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. Measura$le Elements ?. There is an evidence of initial and completion of nursing assessment on the health care needs of each patient within the; 1.1.?st @A hours of admission as an in$patient or earlier as indicated by the patients condition or institutional policy. 1.2.?st @ hours of consultation as an outpatient or earlier as indicated by patients condition or institutional policy. @. There is an evidence of patients reassessment throughout the care process to determine response to intervention at interval appropriate to patients condition. plan of care. individual needs or according to institutional policies and procedures !e.g. Pain is assessed every A hours and as necessary as part of the vital signs monitoring&.

>. Those responsible for direct nursing care collaborate with medical and allied staff to analy/e and integrate the patients assessment data and information. A. Those responsible for direct nursing care prioriti/e patients needs based on assessment results. =. Those responsible for direct patient care inform the patient and family of the assessment outcome and the planned care and treatment regimen and encourage participation of the latter in the decision$ ma*ing about the priority needs to be met. Standard II# Assessment Sco"e % 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. Measura$le Elements ?. 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 Bnowledge level 5anguage spo*en arriers to learning ?.@. Physical Neurological assessment #ardiovascular assessment "espiratory assessment 7astrointestinal assessment 7enitourinary assessment 4usculos*eletal assessment Intergumentary assessment

 Sensory assessment ?.>. Social #ultural concerns ?.A. Spiritual "eligion ?.=. -conomic factor 6inancial barrier ?.C. 2ealth history 'evelopmental history !for pediatrics& 6amily history 4edications ta*en Allergies ?.<. 3ital signs ?.D. Pain assessment ?.E. Nutritional status. needs and ris*s ?.?F.Preference and idiosyncrasies ?.??.'ischarge plan Place; home. e)tended. s*illed care facility Individual who will accompany the patient home !name. address. telephone number. relationship& @. There is an established screening criteria according to patients functional capacity and needs li*e; @.?. Nutritional 8 4etabolic Pattern @.@. -limination Pattern @.>. Activity 8 -)ercise Pattern @.A. Sleep 8 "est Pattern @.=. Se)uality 8 "eproductive Pattern @.C. Sensory 8 Perceptual Pattern @.<. #ognitive Pattern @.D. "ole 8 "elationship Pattern @.E. Self 8 #oncept Pattern @.?F.#oping 8 Stress Tolerance Pattern

@.??.3alue 8 elief Pattern >. %ther pertinent data are collected using the appropriate assessment. technique and instruments.

A. The nursing assessment findings are documented in the individual patients record and readily available to those responsible for his(her care. =. 'ischarge plan is evident in the initial assessment of the nurse particularly to those patients when discharge planning is critical as evidenced by the following; =.?. Age =.@. 5ac* of mobility =.>. #ontinuing medical and nursing needs =.A. Assistance with activities of daily living =.=. "eferral for continuity of care as necessary II$ Standards on Care of atient Standard I# Care Process The Nursing Services 'epartment 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. Measura$le Elements ?. There are e)isting policies and procedures on care process developed by those responsible for governance which include but are not limited on the following;

?.?. ?.@. ?.>.

#are of emergency patients !including use of resuscitation equipment& #are of patient on life support !e.g. ventilatory equipment& #are of patient on dialysis !hemodialysis. peritoneal dialysis& #are of patients at ris*; Neonates #ritically$ill #hildren 4entally disadvantaged :nder anesthesia -lderly 'isabled #are of comatose patient #are of patient with communicable diseases #are of patient in restraint #are of patient on chemotherapy #are of immune $ suppressed patients #are of patient in pain #are of patient on nutritional therapy #are of patient receiving blood and blood components #are of patient receiving medications with narrow margin of safety #are of perioperative patient #are of patient with intravenous therapy

1. There is a written care plan on every patient cared of

@. by the nurse based on patients initial assessment data within the ?st @A hours of assessment or earlier. There is an evidence that family and significant others are involved in the planning process. @.?. Patient participate in planning of care ta*ing into consideration the cultural. religious and other beliefs of patients. -)ample; Selection of food The care plan reflects the related and relevant identified needs and problems of each patient cared for. The care plan ensures that priorities of care are established. The care plan is updated as appropriate based on the reassessment made. The care plan is documented in the individual patients record to promote continuity of care.

?.A.

>. A. =. C.

?.=. ?.C. ?.<. ?.D. ?.E. ?.?F. ?.??. ?.?@. ?.?>. ?.?A. ?.?=.

Standard III# Im"lementation of Care The nurse caring for patients implements nursing intervention and carries out medical orders utili/ing critical thin*ing and sound clinical +udgment for the promotion of health. prevention of illness. alleviation of suffering and restoration of health. Measura$le Elements ?. There is an evidence that nurse caring for patients implements nursing intervention and carries out medical orders utili/ing critical thin*ing and sound clinical +udgment based on but are not limited on the following;

Standard II# Care Plan The nurse caring for patients develops and updates an individuali/ed written care plan in the patients record within the prescribed time frame. Measura$le Elements

?.?. Scope of Nursing Practice as provided by law and all relevant legislations !e.g. The Philippine Nursing Act of @FF@ or "epublic Act E?<>&

The nurse caring for patients systematically and continuously evaluates the patients progress based on the effectiveness of nursing intervention rendered and medical management provided.

?.@. Standard of #are; Acute and #ritical #are Nursing Practice #hronic #are Nursing Practice #ardiovascular Nursing Practice Perioperative Nursing Practice 4aternal and #hild Nursing Practice Psychiatric Nursing Practice -mergency Nursing Practice "enal Nursing Practice Pediatric Nursing Practice %ncology Nursing Practice 7eriatric Nursing Practice -thical and 5egal Nursing Practice Nursing Standard on Intravenous Therapy Infection #ontrol Nursing Practice ?.>. -vidence $ based practice ?.A. Ten !?F& 7olden "ules in 'rug Administration ?.=. #ode of -thics for Nurses ?.C. Patient ill of "ights @. It is evident that implementation of interventions(care is delivered in a safely manner that minimi/es complications and life$threatening situations. Standard IV# E aluation of Care

Measura$le Elements ?. Systematic and continuous evaluation of patients progress and effectiveness of care is reflected in the individuali/ed patient record. @. There is an evidence that evaluation of care and patient outcome occurs within an appropriate time frame after the intervention !nursing or medical& is initiated. >. There is an evidence that patients responses to interventions are documented. A. The revision in care plan if any is reflected in the patient record. Standard V# Pain Management The Nursing Services 'epartment has established pain management guidelines for nurses to appropriately assess. monitor. evaluate and manage patients in pain. Measura$le Elements ?. There is an e)isting pain management guideline for nurses to appropriately assess. monitor. evaluate and manage patients in pain. @. There is evidence that patients receive care according to pain management guidelines.

>. There are e)isting education and training programs for nurses on pain management. A. Processes to communicate with and evaluate patients and families about pain are evident. Standard VI# Medication Management The Nursing Services 'epartment has established policies. procedures and guidelines on medication management for symptomatic. curative. preventive. and palliative treatment of patients diseases and for safe nursing practice. Measura$le Elements ?. There are written policies. procedures and guidelines on medication management which include but are not limited on the following; ?.?. #arrying out physicians medication order ?.@. Transcribing and ordering ?.>. -ndorsing !especially high valuable drugs& ?.A. Preparing ?.=. 5abeling ?.C. Administering !?F 7olden "ules in 'rug Administration& ?.<. 'ocumenting ?.D. 4onitoring and Storage ?.E. -mergency 'rugs ?.?F."egulated 'rugs ?.??.4edication "ecall System !-)pired or %utdated 'rugs& ?.?@."eporting on 4edication effects and adverse effects 4edication error and near$miss Standard VII# End&of&'ife 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 ta*ing into consideration the cultural diversities in beliefs and customs and optimi/e caring environment. Measura$le Elements ?. "espect for patients values. religion and cultural preferences and practices is evident. ?.?. Pastoral services are provided based on the spiritual beliefs of the patient and family. ?.@. The patients right of self$determination and choices are respected and accommodated. ?.>. Advance directives 'o Not "esuscitate. 1aiver. 5iving will if any. are respected. ?.A. 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. @. Assessment. appropriate intervention to alleviate the patients pain and discomfort according to wishes of patient and family and re$assessment are evident. @.?. Pain assessment. intervention and evaluation. are monitored and recorded. @.@. Personal hygiene is rendered based on patients need.

@.>. Nutritional assessment and ris*s are identified and nutritional needs are provided such as feeding and hydration. @.A. Interventions address patient and familys psychosocial. emotional. spiritual and cultural concerns. >. A place is designated for the patients family to stay. A. The patient and family are involved in care management and decision. Standard VIII# Patient and Family Rig(ts The Nursing Services 'epartment has established policies. processes and guidelines that respect and support patient and family rights. Measura$le Elements ?. There are written policies. processes and guidelines that respect and support patient and family rights which include but are not limited on the following; ?.?. Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. ?.@. "espect for patients personal values and beliefs ?.>. "espect the confidentiality of patient health information ?.A. "espect for patients need for privacy !e.g. during treatment. procedure. physical e)amination. clinical interview. transport& ?.=. Protection of patients possessions from theft or loss ?.C. Protection of patient from physical assault !e.g. vulnerable patients are infants. children and elderly&

?.<. Support patient and family rights by participating in the care decision and care process through information of the following; 4edical 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 "efusal or discontinuance of treatment 1ithholding life$sustaining treatments Assessment and management of pain #ompassionate care at the end$of$life Process on complaints and differences of opinion about patient care Participation in clinical research %rgan donation and other tissues 'isclosure of information @. There is evidence that nurses are *nowledgeable and supportive of patient and family rights. III$ Standards on atient and Fami!. Education Standard I# Education Assessment The nurse assesses the educational needs of each patient and family and documents these in his(her patient record. Measura$le Elements ?. 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; ?.?. Patients and familys beliefs and values ?.@. Patients and familys literacy ?.>. Patients and familys educational level

?.A. Patients and familys language ?.=. Patients and familys motivations and emotional barriers ?.C. Patients physical and cognitive limitation ?.<. Patients willingness to receive information Standard II# Education Plan and Programs The Nursing Services 'epartment has established educational plans and programs that support patient and family participation in care decisions and care processes with the primary ob+ective of rehabilitating the patient bac* to his(her functional level and optimal health. Measura$le Elements ?. The educational plan and programs for patient and family are evident according to the type of patient served and his(her learning needs. @. The appropriate structure. methods and mechanism for education is afforded. >. -ducation resources are available and organi/ed in an efficient and effective manner. A. 1hen appropriate. it is evident that the patient and family are educated on topics considered high ris* to patients; A.?. Safe and effective use of medications and their side effects A.@. Preventing interactions between prescribed medications and other medications !over the counter& and food A.>. Safe and effective use of medical equipment A.A. Pain management A.=. "ehabilitation techniques A.C. Treatment and diagnostic procedures IV$

=. It is evident that standardi/ed materials and processes in educating patient and family on the aforementioned topics !A.? to A.=& are available. C. There is an evidence that nurses who provide education have the sub+ect *nowledge. adequate time and communication s*ills to do so. Standards on Access and Continuit. of Care Standard I# Access to Care In diverse health care setting. the Nursing Services 'epartment has established policies and processes on patient access to care aligned with the organi/ation. Measura$le Elements ?. The written policies and processes on patient access to care are evident which include but are not limited on the following; ?.?. #linical services available ?.@. Triage or screening There is evidence that triaging or screening is initiated at the point of ?st contact with the patient ?.>. #riteria for admitting patient or registering out patient ?.A. Process for admitting patient or registering out patient ?.=. 2olding area for patient on observation ?.C. 4anaging 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.

Measura$le Elements ?. There is an evidence that patients with immediate needs(care are assessed. prioriti/ed and received the necessary care as quic*ly as possible according to established physiologically based criteria. @. There is an evidence that staff who responded to emergency patients underwent the necessary training. Standard III# Admitted Patients or In&Patients The needs of in$patients for preventive. curative. rehabilitative and palliative services as well as other relevant information are assessed and prioriti/ed based on his(her health condition at the time of admission in the health care facility. Measura$le Elements ?. There is an evidence that nurse screening assessment focuses on preventive. curative. rehabilitative and palliative services and prioriti/es these according to the patients health condition. @. 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;

@.?. Proposed plan of care @.@. -)pected outcome of care @.>. -)pected cost of care @.A. Sufficient information to ma*e *nowledgeable decision and @.=. 5imit or overcome barriers such as language. cultural. physical. to access and in the delivery of care Standard IV# Intensi e and S"eciali)ed Ser ices The Nursing Services 'epartment has established entry( or transfer criteria for patients that need intensive and speciali/ed services to meet special patient needs congruent with those of the organi/ation. Measura$le Elements ?. There is an evidence of entry(or transfer criteria for patients that need intensive and speciali/ed services to meet special patient needs. @. It is evident that criteria is physiologic$based and developed by appropriate individuals. >. It is evident that patients admitted and or transferred to intensive and speciali/ed areas(units meet the established criteria and are documented in the patient record. A. There is an evidence that nurses caring for patients needing intensive and speciali/ed services underwent the related and necessary training. Standard V# Continuity of Care In diverse health care setting. the Nursing Services 'epartment has established policies and processes on patient continuity of care aligned with those of the organi/ation and coordinated among other health professionals.

Measura$le Elements ?. The written policies and processes on patient continuity of care are evident and implemented throughout all phases of patient care particularly but are not limited in the following services; ?.?. -mergency services to nursing ward admission ?.@. Nursing ward services to diagnostic services ?.>. Nursing ward services to surgical and non$ surgical services ?.A. etween nursing units or clinical departments ?.=. Nursing ward services to intensive or special services ?.C. %ut patient care programs ?.<. %ther health care settings @. 'uring all phases of care. there is a qualified individual. identified as responsible for patient care and documented in the patient record. >. #ontinuity of care and coordination of services are evident throughout all phases of care. Standard VI# Disc(arge* +ut on Pass* Referral and Follo,&u" The Nursing Services 'epartment has established policies and processes and guidelines on patients discharge. out on pass. referral and follow$up congruent with those of the organi/ation. Measura$le Elements ?. There are written policies. procedures and guidelines on patients discharge. out on pass. referral and follow$up congruent with those of the organi/ation.

@. There are criteria that determine patients readiness to be discharged. >. There is a process on out on pass patients for a defined period of time. A. There is a referral system of patients for transfer to other organi/ation. =. The patients discharge summary is prepared by qualified individuals recogni/ed by the organi/ation. C. A copy of patients 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; C.?. "eason for admission C.@. Significant physical and other findings C.>. Significant diagnosis and co$morbidities C.A. 'iagnostic and therapeutic procedures performed C.=. 4edications and treatments C.C. 4edications to be ta*en at home C.<. #ondition of patient at the time of discharge C.D. 6ollow$up instruction in an understandable form and manner Activity 'iet Ne)t medical consultation :rgent care indicators C.E. "eferral for support services to either health care providers. health organi/ations or agency. and health professionals in the community. Standard VII# -ransfer of Patient The Nursing Services 'epartment has established policies. procedures and guidelines regarding the transfer of patient within and outside of the organi/ation.

Measura$le Elements ?. There is a written policy. procedure and guidelines on transfer of patient within and outside of the organi/ation. @. The guidelines and procedures include but are not limited on the following; @.?. Transfer is based on the patients needs for continuity of care. @.@. Transfer of responsibility to another health provider or health care setting is evident. @.>. "esponsible health care provider during the patients transfer is identified. @.A. 6ormal and informal arrangements are apparent. @.=. Summary of patients clinical condition. interventions !medical and nursing& and continuous care rendered are written. @.C. Situation when transfer is not possible is stated. @.<. Patients transfer is documented. @.D. Safe and quality medical transport services within and outside of the organi/ation are provided. V$ Standards on Nursing Documentation Standard I# Structural Data

applicable forms which include but are not limited on the following; ?.?. Patients addressograph 8 name. age. gender. civil status ?.@. "egistration number and or Admission number ?.>. 'ate and time of admission and discharge ?.A. 4ode of admission(transport(discharge ?.A.?. Admitted via; ambulatory. wheelchair. stretcher ?.A.@. Admitted from; home. transferring hospital. care facility ?.=. Attending physician and referring physician. if any ?.C. "eligion ?.<. 5anguage spo*en ?.D. Advance directive ?.E. 2ealth #are Insurance Standard II# Clinical Data The nurse documents essential clinical data of each patient accurately and completely based on individuali/ed nursing care plan from admission to discharge in health care facility. Measura$le Elements

The nurse documents structural data of each patient accurately and completely based on applicable laws and regulations. professional standards and institutional requirements. Measura$le Elements ?. There is an accurate and complete documentation of patients structural data in all nursing and

?.

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; ?.?. Physical e)amination !head$to$toe& ?.@. 2ealth history

?.>. ?.A. ?.=. ?.C. ?.<. ?.D. ?.E. ?.?F.

Psychological. social. spiritual and economic evaluation Actual and potential health problems and needs 'iagnostic and therapeutic interventions Pharmacological management Nursing interventions 2ealth teachings 8 patient and family Patients response and outcome Preferences and idiosyncrasies

AD-INISTRATION 1 -ANAGE-ENT
I$ Standards on Governance and Direction Standard I# .o ernance Structure The Nursing Services 'epartment 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. Measura$le Elements ?. The Nursing Services governance structure is represented or displayed in an organi/ational chart that shows functional and positional relationships and span of control. @. The Nursing Services governance structure is described in written documents with the approval of proper authority. >. The Nursing Services governance structure depicts decentrali/ation or unit$based wherein decision$ ma*ing prevails to support and promote patient safety and quality improvement. A. The Nursing Services governance structure and processes support professional communication. clinical planning and services and policy development. Standard II# .o ernance Accounta$ility Res"onsi$ility and

The governance responsibility and accountability are described in a written document to guide how they are to be carried out. Measura$le Elements ?. The governance responsibility and accountability are described in organi/ations by$laws. +ob description and other similar documents. @. Those responsible and accountable for governing and managing the Nursing Services 'epartment are identified by position title and name. >. 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 'epartment. A. 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 'epartment has an established vision. mission. philosophy. core values and quality ob+ectives congruent with that of the institution and the Nursing profession. Measura$le Elements ?. Those responsible for the Nursing Services 'epartment governance. primarily sets its direction by formulating its vision. mission. philosophy. core values and quality ob+ectives 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 operationali/ed. Standard IV# Strategic % +"erational Plans The Nursing Services 'epartment has documented strategic and operational plans consistent with the hospital wide quality plan. Measura$le Elements ?. Those responsible for governance forecast and direct the future and operation of the Nursing Services 'epartment in order to achieve its overall goals. @. There is an e)istence of strategic and operational plans periodically set and reviewed which contains goals and ob+ectives. action plan(activities. timeframe. resources required and contingencies. >. Those in the managerial and clinical levels translate the overall Nursing Services 'epartment strategic and management plans into action which include; the management of patient care. nursing manpower and unit operation of responsibility areas. Standard V# Financial Plan % Resource Allocation The Nursing Services 'epartment has financial plan and allocation of resources required to meet its goals and sustain its operation. Measura$le Elements ?. Those responsible for governance have established current financial plans and allocation of resources based on the needs of the Nursing Services 'epartment.

@. The capital and operating budgets are implemented as approved by the authori/ed person(office and monitored based on responsibility accounting. >. -ach Nursing :nit has an individual budget plan periodically monitored for variances. A. The medical supplies. materials and equipment recommended by professional organi/ations and authoritative sources are obtained and appropriately used. Standard VI# Policies % Procedures De elo"ment The policies and procedures of the Nursing Services 'epartment that reflect Standards of Nursing Administration. Nursing Practice on Patient #are are developed and communicated to serve as operational guidelines. Measura$le Elements ?. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient #are. @. An updated manual of Nursing Services policies and procedures e)ists and provides clear directive for nursing personnel at different levels on the scope and limitations of their functions and responsibilities to patient care. Standard VII# Et(ico / Moral % 'egal Accounta$ilities The Nursing Services 'epartment has an established framewor* for ethico$moral and legal management to support the ethical decision$ma*ing in the clinical areas. and

conforms with the applicable statutory laws. rules and regulations. Measura$le Elements ?. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico$moral dilemmas in patient care. @. Those responsible for governance ensure compliance with the applicable statutory laws. regulations and standards. >. The Nursing Services 'epartment has a written #ode of -thical ehavior which observes the rights and safety of patients and health care providers. Standard In ol ement VIII# Professional % +rgani)ational

The administrator of the Nursing Services 'epartment actively participates and collaborates with leaders within the organi/ation and professional associations for continuous quality improvement of nursing services. Measura$le Elements ?. Those responsible for Nursing Services 'epartment governance initiate and maintain formal liaison(lin*age 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.

?.?.A. II$ Standards on /uman Resource -anagement Standard I# Administrator of Nursing Ser ices The Nursing Services 'epartment is administered by a qualified nursing administrator pertinent to licensure. appropriate education. e)perience and demonstrable proven ability in nursing practice and administration. fully responsible and accountable for the operation of the entire Nursing Services of the organi/ation(institution. Measura$le Elements ?. There are presence of evidences that the Nursing Service Administrator is qualified to the position based on "A E?<> and other criteria set by the organi/ation(institution such as; ?.? 9ualifications of Nursing Service Administrators; A person occupying supervisory or managerial positions requiring *nowledge of nursing must; ?.?.?. e a registered nurse in the Philippines, ?.?.@. 2ave at least two !@& years e)perience in general nursing service administration, ?.?.>. Possess a degree of bachelor of Science in Nursing. with a least nine !E& units in management and

administration courses at the graduate level, and e a member of good standing of the accredited professional organi/ation of nurses.

?.@. A person occupying the position of chief nurse of director of nursing service shall. in addition to the foregoing qualifications. possess; ?.?.?. At least five !=& years of e)perience in a supervisory or management position in nursing, and ?.?.@. A masters degree ma+or in nursing. ?.>. That for primary hospitals. the ma)imum academic qualifications and e)periences for a chief nurse shall be as specified in subsections !?.?.?&. !?.?.@.&. and !?.?.>& of the above. ?.A. That for chief nurses in the public health agencies, those who have a masters degree in public health(community health nursing shall be given priority. ?.=. That for chief nurses in military hospitals. priority shall be given to those who have finished a masters degree in nursing and the completion of the 7eneral Staff #ourse !7S#&. @. Those responsible for the overall administration and management of Nursing Services is a member of the top -)ecutive(4anagement #ommittee who participates in their regular meetings and provides advice and recommendations in relation to nursing practice. Standard II2 Staffing Plan

The Nursing Services 'epartment 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.

Measura$le Elements ?. Those responsible for Nursing Services governance develop a staffing plan that identify the number. type and desired qualification !education. s*ills and e)perience& of Nursing Services staff. reviewed and updated on an ongoing basis. @. Those responsible for Nursing Services governance consider the organi/ations mission. type of services. level and modality of care. patients mi). staff and s*ills mi) and other factors affecting the pro+ection of staffing needs. >. The staffing plan is defined in writing and meets the needs of the patients(population served and scope of services. Standard III# Recruitment* Selection* Hiring and A""ointment The Nursing Services 'epartment has an established system and processes for recruitment. selection. hiring. appointment and promotion of human resources in accordance with the statutory laws and regulations and the institutional policies and procedures. Measura$le Elements ?. 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. @. There are legitimate and legitimi/ed processes to recruit. select. hire and appoint nursing services personnel and are uniformly implemented. >. Staff recruitment. selection. hiring and appointment are based on institutional. patients needs and applicant qualification. Standard IV# Credentialing The Nursing Services 'epartment has an effective process for gathering. verifying and evaluating the nursing staff credentials. Measura$le Elements ?. Those responsible for Nursing Services governance develop an effective process for gathering. verifying and evaluating the nursing staff credentials !licensure. education. training. wor* e)perience& and other pertinent requirements. @. There is evidence of standardi/ed procedure to gather the credentials of all nursing staff. >. The licensure. education. training and wor* e)periences of nursing personnel are documented and updated. Standard V# Staff Placement The Nursing Services 'epartment has defined criteria and processes to ensure the clinical staff *nowledge and s*ills are consistent with the patients needs.

@. There is evidence that the 0ob 'escription of Nursing Services personnel is reviewed at least once every > years and revised when necessary. Measura$le Elements ?. Those responsible for Nursing Services governance develop and define the criteria !core competencies& and processes to match the clinical staff *nowledge and s*ills with the patients needs. @. There are written core competencies required for every +ob position in the Nursing Services organi/ation to ensure that the staff s*ills are consistent with the patients needs. >. Staff placement(assignment is based on patient needs. available resources and staff competencies. Standard VI# Staff 0o$ Descri"tion The Nursing Services 'epartment has +ob description for each position classification of Nursing personnel. which specifies duties and responsibilities based on established standards of performance. Measura$le Elements ?. There is a written 0ob 'escription for each position classification of Nursing Services personnel which specifies; ?.?. 'uties and responsibilities ?.@. Accountability ?.>. 6unctional relationship ?.A. 9ualification and e)perience required Standard VII# Staff De elo"ment The Nursing Services 'epartment has an established staff development program for all nursing personnel to encourage and promote continuing personal and professional growth and development. Measura$le Elements ?. 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 throughout the year which include; a. %rientation program for newly hired and promoted staff. to the organi/ation department(unit to which they are assigned as well as their specific +ob responsibilities. b. Safety program to protect the patient. staff and property. c. #ontinuing education. training and opportunities for professional advancement of staff member to enhance their *nowledge and s*ills. d. #areer counseling and career advancement(ladder. >. "esources are available to implement the staff development program such as;

>.?. Space and facilities >.@. -ducational resources >.>. #linical and clerical staff >.A. Audiovisual equipment >.=. "esource spea*ers A. Policies and procedures on continuing education staff attendance to staff development programs are evident. =. "ecords of staff development program are maintained which include; =.?. Title of the program =.@. %b+ectives of the program =.>. Program design and content =.A. -valuation of the attendees =.=. -ffectiveness of the program =.C. 5ist of attendees(participants III$ Standards on Faci!it. -anagement 1 Environment Safet. Standard I2 Facility Planning 6or efficient and effective delivery of nursing care and services. the Nursing Services 'epartment provides a safe. functional and supportive facility to patients and their families. staff and visitors aligned with that of the organi/ations master plan. Measura$le Elements ?. Those responsible for governance comply with relevant laws. regulations and other requirements that are applicable.

@. Those responsible for governance actively participate in space planning as well as medical equipment and supplies procurement. >. Those responsible for governance. plan and budget for upgrading or replacing *ey components based on facility inspection findings. Standard II2 En ironmental Safety The Nursing Services 'epartment actively participates in the planning. implementation and evaluation of hospital 8 wide programs to provide a safe and secure physical environment. Measura$le Elements ?. There is a written and up$to$date plan. implementation and evaluation of programs(activities to manage the ris*s within the environment which includes but is not limited on the following; ?.?. Safety and Security There is an e)isting provision for the identification of patient and their families. visitors. staff and others. 4onitoring mechanism of all ris* areas is in place and *ept secure to patient from unauthori/ed access or use. tampering. destruction or loss. !e.g. 4edication "oom& ?.@. 2a/ardous 4aterials and 1aste There is a current list of ha/ardous materials and waste to safely control them !e.g. chemotherapeutic agents. chemicals. radio$active materials and waste.

ha/ardous gases and vapors. infectious waste&. There is an e)isting written processes on handing. labeling. storage. use. inventory and disposal of ha/ardous materials and waste. 'ocumentation and reporting system are in place for investigation of spills. e)posures and other accidents related to ha/ardous materials and wastes.

institutional emergencies. epidemics. and disasters.

?.>. 4edical -quipment There is an updated policy and processes on medical equipment procurement. inventory. regular inspection. preventive maintenance. and recall system. 4onitoring of equipment functionality and utili/ation is in place for purposes of planning and improvement. ?.A. :tilities Potable water. electrical power. and medical gases are available @A hours a day. seven !<& days a wee*. A written emergency processes is in place in the event of water interruption or contamination. electrical failure or interruption and medical gases unavailability. 4onitoring of utilities is evident for purposes of planning and improvement. ?.=. -mergencies An emergency management plan and processes are evident to li*ely community(

?.C. 6ire Safety There is an evidence that fire safety plan and program of the organi/ation(institution is implemented in a continuous and comprehensive manner to all patient care and staff wor* areas. ?.<. Infection #ontrol 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 ris*s 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 III2 Staff Education The Nursing Services 'epartment ensures education and training of staff to effectively carry out their roles in creating a safe and sound patient and staff environment. Measura$le Elements

?. There is an evidence of staff education and training on facility management and environmental safety programs. @. There is an evidence that the staff can describe and demonstrate their role in the aforementioned safety programs. >. There is an evidence of staff training to operate medical equipment appropriate to their +ob description. VI$ Standards on Communication -anagement Standard I2 Communication of Information The Nursing Services 'epartment has efficient and effective system of communication with the community. to patients and their families. nursing personnel and other health professionals throughout the organi/ation. Measura$le Elements ?. There is efficient and effective system of communication that e)ist which include but are not limited on the following; ?.?. #ommunity Patient(nursing care services 2ealth programs Process to access care ?.@. Patients and 6amilies Patient health condition #are provided to patient Patients response to care Patient(nursing care services available Alternative sources of care and services Process to access care

-ducational materials and methods in an understandable format and language

?.>. Nursing Personnel Nursing endorsement in between wor* shifts Nursing documentation "eferral Nursing Service Philosophy. 3ision. 4ission. #ore 3alues Policies. Procedures. 7uidelines. Standards 4emorandum. #ircular. 'irectives. Activities ?.A. %ther 2ealth Professionals !clinical and non$ clinical staff& Patient care and response to care !referral& Patient clinical data !diagnostic e)aminations and therapeutic procedures& #ircular Standard II2 Patient Clinical Record The Nursing Services 'epartment has established policies. procedures and guidelines on patient clinical record. Measura$le Elements ?. There are written policies. procedures. and guidelines on patient clinical record which include but are not limited on the following; ?.?. #linical record for every patient assessed or treated. in$patient or out$patient ?.@. #onfidentiality of record ?.>. Security of record

Protection from loss and destruction and unauthori/ed access and use ?.A. 'ata Integrity Protection from tampering ?.=. :se and monitoring of standardi/ed abbreviations. symbols. procedure codes and definitions ?.C. "etention period of records !as prescribed by law and institutional policy& Standard III2 Administrati e Record The Nursing Services 'epartment has established policies or protocol in *eeping and maintaining its administrative record and defining the requirements for developing and maintaining policies and procedures. Measura$le Elements ?. There is a written policy or protocol in *eeping and maintaining Nursing Services 'epartment administrative records which include but are not limited on the following; ?.?. %rgani/ation and Nursing Services 'epartment Policies. Procedures. 7uidelines ?.@. Standards ?.>. 4aster Staffing Plan ?.A. Staffing Pattern ?.=. #ensus of Patients and 'iseases ?.C. ed #apacity and %ccupancy "ate ?.<. udget Plan ?.D. Staff 'evelopment Programs ?.E. #ommittees. Nursing and the %rgani/ation ?.?F.4inutes of 4eeting. Nursing Services 'epartment

?.??.9uality Improvement Program and other Pro+ects ?.?@.4anuals of the %rgani/ation 9uality System Infection #ontrol -mergency Preparedness -mployees 4anual %thers @. There is written policy or protocol in developing and maintaining policies and procedure which include but are not limited on the following; @.?. "eview and approval of all policies and procedures before implementation @.@. Process and frequency of review and continued approval of policies and procedures @.>. #ontrol that only current policy and procedures are implemented @.A. Identification of charges in policy and procedures @.=. "etention of obsolete policies and procedures @.C. "eferences originating outside the organi/ation @.<. Trac*ing of policy and procedures in circulation !e.g. title. date of issue. authori/ed person& V$ Standards on 0ua!it. Im"rovement Standard I2 'eaders(i" and Staff Education The Nursing Services 'epartment has continuous quality improvement on patient and staff safety programs through monitoring and analy/ing variation of data and undesirable trends of events. Measura$le Elements

?. Those responsible for governing and managing the Nursing Service 'epartment lead or actively participate in planning. monitoring. analy/ing and implementing quality improvement and patient and staff safety programs congruent with the organi/ational needs. @. 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 training program for staff consistent with their role in quality improvement and patient safety program. A. There is a qualified trainer who provides the training and staff participation as part of their regular wor* assignment. =. There is an established reporting system on the quality and safety programs to governance. C. Those in governance support and ta*e action on recommendation for quality improvement and patient and staff safety programs based on the result of root cause analysis. Standard II2 !uality Programs The Nursing Services 'epartment has priority quality programs to reduce high volume. high ris* and problem$ prone processes. Measura$le Elements ?. There is written plan or policy or document of a well designed new processes or modified e)isting processes consistent with current practice. guidelines. clinical standards. scientific literature.

and other relevant evidence 8 based information. !e.g. 4edication safety. clinical pathway& @. There is an e)isting plan and program to reduce the ris* of community(hospital acquired infectious for patients and health care associated infections for staff. >. 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 III2 !uality Monitoring* Analysis % Im"lementation The Nursing Services 'epartment has established *ey indicators to monitor the clinical and managerial structure. processes and results and data are aggregated. analy/ed and transformed to useful information. Measura$le Elements ?. There is a clinical monitoring that e)ists but is not limited on the following; ?.?. #linical research ?.@. Nursing documentation ?.>. 4edication error ?.A. Intravenous fluids ?.=. lood and blood products ?.C. Total parenteral nutrition ?.<. Surgical safety !sterili/ation(disinfection& ?.D. Infection control. surveillance. reporting !needle stic* in+ury. hand hygiene and barrier technique. body fluids and waste segregation(disposal& ?.E. Prevention and control measures aligned with International Patient Safety 7oals. !Isolation Procedure&

@. There is a managerial monitoring that e)ists but is not limited on the following; @.?. Patient demographics and clinical diagnoses @.@. Patient and family e)pectations and complaints. if any @.>. Availability of drugs and medical supplies essential to most patient needs !e.g. -mergency Bart contents& @.A. 6inancial budget @.=. 4anpower utili/ation @.C. Staff e)pectations and satisfaction @.<. Incident reports and sentinel events @.D. "eports as required by law and regulation and those in governance >. There is an evidence data analysis and actions ta*en. A. There is an evidence that actions for improvement are appropriate to the care. scope and severity of the problems. =. There is an evidence that the actions for improvement or changes are planned. tested and implemented. C. There is a written available data to demonstrate that the improvements are effective and sustained.

G,OSSAR3
Adverse Event 8 is an unanticipated or potentially dangerous occurrence in health care organi/ation. C!inica! ath4a.s 8 is an agreed$upon treatment regime that includes elements of care. Communication -anagement 8 is the creation. use. sharing and disposal of data or information for effective and efficient operation of organi/ation activities. It includes the role of management to produce and control the use of data and information in wor* activities. information resources management. information technology. and information services. Continuit. of Care 8 is the matching of an individuals 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 organi/ation or across multiple organi/ations. Credentia!ing 8 is the process of obtaining. verifying. and assessing the qualifications of a health care practitioner li*e the nursing personnel. The process determines if an individual can provide patient care services in or for a health care organi/ation. Discharge Summar. 8 is a section of patient record that summari/es the reasons for admittance. the significant findings. the procedures performed. the treatment rendered. the patients condition on discharge. and other specific

instructions given to the patient or family !for e)ample. follow 8up. medications&. End5of5,ife Care 6 is the provision of care to the patient whose disease condition is not responsive to curative treatment. and his(her life e)pectancy is estimated to be within days or months. Governance 8 refers to the individual!s&. group or agency that have ultimate authority and responsibility for establishing policy. maintaining quality of care. and providing for organi/ation management and planning. %ther names for this group include Gboard.H Gboard of trustees.H board of governors.H Gboard of commissioners.H and Ggoverning body.H /ea!th Care Organi7ation 8 is a generic term used to describe many types of organi/ations that provide health care services. This includes ambulatory care centers. behavioral(mental health institutions. home care organi/ations. hospitals. laboratories and long term organi/ations. It is also *nown as a Ghealth care institution.H /ea!th Care rofessiona! 8 is any person who has completed a course of study and is s*illed in a field of health. This includes a physician. dentist. nurse. or allied health professionals. 2ealth care professionals are often licensed by a government agency or certified by a professional organi/ation. Indicator 8 is a measure of the performance of functions. systems. or process. over time. Informed Consent 6 is an agreement or permission accompanied by full information on the nature. ris*s. and alternatives of a medical procedure or treatment before the

physician or other health care professional begins the procedure or treatment. In5Service Education 6 is an organi/ed education. usually provided in the wor*place. designed to enhance the s*ills of staff members or teach them new s*ills relevant to their +obs and disciplines. a!!iative Services 6 are treatments and support services intended to alleviate pain and suffering rather than to cure illness. atient Record8C!inica! Record 6 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. !an of Care 6 is a plan that identifies the patients care needs. lists the strategy to meet those needs. documents treatment goals and ob+ectives. outlines the criteria for ending intervention. and documents the individuals progress in meeting specified goals and ob+ectives. It is based on data gathered during patient assessment. The format of the plan in some organi/ations 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. 0ua!ified Individua! 6 is an individual or staff member who can participate in one or all of the organi/ations care activities or services. 9ualification is determined by the following; education. training. e)perience. competence. applicable licensure. law or regulation. registration. or certification.

0ua!it. of Care 8 is the degree to which health services for individuals and populations increase the li*elihood of desired health outcomes and are consistent with current professional *nowledge. Safet. 6 is the degree to which the ris* of an intervention and ris* in the care environment are reduced for a patient and other persons. including health care providers. Standard 8 is a statement that defines the performance e)pectations. structures. or process that must be in place for an organi/ation to provide safe and high$quality care. treatment. and service. Standard of Nursing ractice 6 is an authoritative statements that describe the responsibilities for which nursing practitioners are accountable. Outcome Standards 8 'escribes the basis level of care the patient can e)pect to receive.

REFERENCES
Association of Nursing Service Administrators of Philippines. Inc. !@FF?& Standards of Nursing Services the

Association of Nursing Service Administrators of the Philippines. Inc. and Philippine Nurses Association. Inc. !?EEE&. Standards of Safe Nursing Practice #ommittee on the "evision of the 2ospital Nursing Service Administrative 4anual !?EEF&. The Administration of 2ospital Nursing Services in Philippine 'epartment of 2ealth. ?st -dition 0oint #ommission International !@FFD&. Accreditation Standards for 2ospitals. >rd -dition Printed in :SA =A>@? 0oint #ommission International !@FFA&. #redentialing. -dition Printed in :SA =A>@? 0oint #ommission International !@FFA&. 2uman "esources for 2ospitals. -dition Printed in :SA =A>@? Noe. 2ollenbac*. 7erhart. 1right !@FFA&. 6undamental of 2uman "esource 4anagement. 4c7raw$2ill #o. Inc. New Ior* "epublic Act E?<> or The Philippine Nursing Act of ?EE?. "epublic of the Philippines. 4etro 4anila "obbins. S. #oulter 4 !@FFA&. 4anagement. <th -dition. Pearson -ducation South Asia PT- 5T'.

"owland 2 J "owland !?EDF&. 2andboo*. Aspen Publication

Nursing Administration

Tomey A.4 !@FFA&. 7uide to Nursing 4anagement and 5eadership. <th -dition 1eber. 0 !@FFC&. Nurses 2andboo* of 2ealth Assessment. = th -dition. 5ippincott 1illiams J 1il*ins