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 TA+,E OF CONTENTS

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
Introduction
quality of patient care and management of nursing services in the
C!inica! Services
Philippines.
 I. Standards on Assessment of Care
The development was actively participated by the oard Standard I. Assessment Process
of Nursing !P"#$%N& and the ANSAP’s oard of 'irectors
Standard II. Assessment Scope and #ontent
and validated by the #hief Nurses(Nursing 'irectors who are
also members of ANSAP. The initial draft was eventually  II. Standards on Care of Patient 
reviewed and discussed by opinion leaders in focus group of  Standard I. #are Process
e)perts. The final blueprint was presented to public hearing Standard II. #are Plan
Standard III. Implementation of #are
attended by *ey sta*eholders around the country.
Standard I3. -valuation of #are
Standard 3. Pain 4anagement
This edition contains a complete set of standards Standard 3I. 4edication 4anagement
 presented in two ma+or components namely, the #linical and Standard 3II. -nd$of$5ife #are
Administration management. -ach component has five Standard 3III. Patient and 6amily "ights
standards criteria and measurable elements necessary to help  III. Standards on Patient and Family Education
organi/ations educate the staff. Standard I. -ducation Assessment
Standard II. -ducation Plan and Programs
This edition is also a cross$reference to corresponding
 IV. Standards on Access and Continuity of Care
requirements set forth in the Philippines by ANSAP and the
Standard I. Access to #are
international accrediting body li*e 0oint #ommission Standard II. -mergency Patients
International !0#I&. Standard III. Admitted Patients or In$Patients
Standard I3. Intensive and Speciali/ed Services
1e view that standards are continuously a wor* in
Standard 3. #ontinuity of #are
 progress. 2ence we welcome any comments and suggestions Standard 3I. 'ischarge %ut on Pass "eferral and 6ollow$up
for improvement. Standard 3II. Transfer of Patient

V. Standards on Nursing Documentation

Standard I. Structural 'ata
Standard II. #linical 'ata
 

Administration and -anagement INTRODUCTION

 I. Standards on overnance and !irection
This manual is designed to assist health organi/ations or 
Standard I. 7overnance Structure
Standard II. 7overnance "esponsibility and Accountability
hospitals with the significant standards necessary to deliver 
Standard III. 'irection$Setting quality nursing service to our clients. To achieve this this
Standard I3. Strategic and %perational Plans designed manual has two components, #linical and
Standard 3. 6inancial Plan and "esource Allocation Administration and 4anagement.
Standard 3I. Policies and Procedures 'evelopment
Standard 3II. -thico 8 4oral and 5egal Accountabilities The first part is #linical Services. This component focuses
Standard 3III. Professional and %rgani/ational Involvement on defining what the standards are in the clinical setting.
:tili/ing nursing process 8 there are five identified standards to
 II. Standards on Human Resource Management wit;
Standard I. Administrator of Nursing Services
Standard II. Staffing Plan
Standard III. "ecruitments Selection 2iring and Appointment
I. Standards on Assessment of Care . #lassified
Standard I3. #redentialing under are two criteria which include the process and
Standard 3. Staff Placement scope and content of assessment.
Standard 3I. Staff 0ob 'escription
Standard 3. Staff 'evelopment II. Standards on Care of atient. There are seven !<&
identified criteria that identify care process care
 III. Standards on Facility Manageme nt and Enironment   plan implementation of care and evaluation of care
 Safety
rendered. Included also is the medication
Standard I. 6acility Planning
management and the family rights.
Standard II. -nvironmental Safety
Standard III. Staff -ducation
III. Standards on atient and Fami!. Education has
 IV. Standards on Communication Manag ement  two criteria in which the nurse’s independent role in
Standard I. #ommunication of Information  providing health education is hereby identified.
Standard II. Patient #linical "ecord
Standard III. Administrative "ecord I3. Standards on Access and Continuit. of Care .
There are seven !<& criteria that guide the nurses
V. Standards on !uality Im"roement 
regarding the importance of access to care. These
Standard I. 5eadership and Staff -ducation
standards identify the need to establish policies and
Standard II. 9uality Programs
 procedures from admission to discharge and r eferral
Standard III. 9uality 4onitoring Analysis and Implementation
follow up.
 

needed in the delivery of nursing services and

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.
training of personnel to effectively carry out their 
respective roles.
I3. Standards on Communication -anagement .
Three !>& 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.

The second part is the Administration and 4anagement. 3. Standards on 0ua!it. Im"rovement . This
This concerns managing the nursing services in the hospital. standard has three !>& criteria which address the
There are five !=& standards identified; need to institutionali/e continuous quality and
 performance improvement.
I. Standards on Governance and Direction . There
are seven !<& criteria included. This chapter  -ach standard and criteria has identified measurable
recommends the need for organi/ational structure elements intended to provide clarity to the standards and to help
which will delineate responsibility accountability organi/ations develop their own policies and procedures
and authority of nursing administration. These focus according to the standards.
also on planning direction organi/ation and
controlling functions of the nursing service
administration and their relationship with other 
services.

II. 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.

III. Standards on Faci!it. -anagement and

Environmenta! Safet.. This standard contains
three !>& criteria and covers environmental safety
 

>. Those responsible for direct nursing care collaborate

with medical and allied staff to analy/e and integrate
the patient’s assessment data and information.
. 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
C,INICA, SERVICES encourage participation of the latter in the decision$
ma*ing about the priority needs to be met.
I$ Standards on Assessment of Care
 Standard II# Assessment Sco"e % Content 
 Standard I# Assessment Process
The scope and content of nursing assessment are well
defined in an institutional policy wherein those elements
The nurse identifies the health care needs of each patient
common to all assessments and any differences with other 
 based on an established assessment process and within the
health disciplines are identified.
 prescribed timeframe.
 Measura$le Elements
 Measura$le Elements

?. There is a well defined policy on nursing assessment

?. There is an evidence of initial and completion of 
in terms of scope and content which include but are
nursing assessment on the health care needs of each
not limited on the following;
 patient within the;
st 1.1. Psychological
1.1.? @ hours of admission as an in$patient or 
Bnowledge level
earlier as indicated by the patient’s condition or 
institutional policy. 5anguage spo*en
st
1.2.? @ hours of consultation as an outpatient or  arriers to learning
earlier as indicated by patient’s condition or  ?.@. Physical
institutional policy.  Neurological assessment
@. There is an evidence of patient’s reassessment #ardiovascular assessment
throughout the care process to determine response to "espiratory assessment
intervention at interval appropriate to patient’s 7astrointestinal assessment
condition plan of care individual needs or  7enitourinary assessment
according to institutional policies and procedures 4usculos*eletal assessment
!e.g. Pain is assessed every  hours and as necessary Intergumentary assessment
as part of the vital signs monitoring&.
 

Sensory assessment @.??.3alue 8 elief Pattern

?.>. Social >. %ther pertinent data are collected using the
#ultural concerns appropriate assessment technique and instruments.
?.. Spiritual
"eligion
?.=. -conomic factor 
6inancial barrier 
. The nursing assessment findings are documented in
the individual patient’s record and readily available
?.C. 2ealth history to those responsible for his(her care.
'evelopmental history !for pediatrics& =. 'ischarge plan is evident in the initial assessment of 
6amily history the nurse particularly to those patients when
4edications ta*en discharge planning is critical as evidenced by the
following;
Allergies
=.?. Age
?.<. 3ital signs
=.@. 5ac* of mobility
?.D. Pain assessment
=.>. #ontinuing medical and nursing needs
?.E. Nutritional status needs and ris*s
=.. Assistance with activities of daily living
?.?F.Preference and idiosyncrasies
=.=. "eferral for continuity of care as necessary
?.??.'ischarge plan
Place; home e)tended s*illed care
II$ Standards on Care of atient
facility
Individual who will accompany the patient  Standard I# Care Process
home !name address telephone number
relationship& The Nursing Services 'epartment has an established
@. There is an established screening criteria according uniform care process across the clinical setting that reflects
to patients’ functional capacity and needs li*e; integration and coordination of care of other health team
@.?. Nutritional 8 4etabolic Pattern members particularly to those patients with similar 
@.@. -limination Pattern condition.
@.>. Activity 8 -)ercise Pattern
@.. Sleep 8 "est Pattern  Measura$le Elements
@.=. Se)uality 8 "eproductive Pattern
@.C. Sensory 8 Perceptual Pattern ?. There are e)isting policies and procedures on care
@.<. #ognitive Pattern  process developed by those responsible for 
@.D. "ole 8 "elationship Pattern governance which include but are not limited on the
@.E. Self 8 #oncept Pattern following;
@.?F.#oping 8 Stress Tolerance Pattern
 

?.?. #are of emergency patients !including use 1. There is a written care plan on every patient cared of 
of resuscitation equipment&  by the nurse based on patient’s initial assessment
?.@. #are of patient on life support !e.g. st
data within the ? @ hours of assessment or earlier.
ventilatory equipment&
@. There is an evidence that family and significant
?.>. #are of patient on dialysis !hemodialysis
others are involved in the planning process.
 peritoneal dialysis&
@.?. Patient participate in planning of care ta*ing
into consideration the cultural religious and
other beliefs of patients. -)ample;
?.. #are of patients at ris*; Selection of food
 Neonates #ritically$ill >. The care plan reflects the related and relevant
#hildren 4entally disadvantaged identified needs and problems of each patient cared
-lderly :nder anesthesia for.
'isabled . The care plan ensures that priorities of care are
?.=. #are of comatose patient established.
?.C. #are of patient with communicable diseases =. The care plan is updated as appropriate based on the
?.<. #are of patient in restraint reassessment made.
?.D. #are of patient on chemotherapy C. The care plan is documented in the individual
?.E. #are of immune $ suppressed patients  patient’s record to promote continuity of care.
?.?F. #are of patient in pain
?.??. #are of patient on nutritional therapy  Standard III# Im"lementation of Care
?.?@. #are of patient receiving blood and blood
components The nurse caring for patients implements nursing
?.?>. #are of patient receiving medications with intervention and carries out medical orders utili/ing critical
narrow margin of safety thin*ing and sound clinical +udgment for the promotion of 
?.?. #are of perioperative patient health prevention of illness alleviation of suffering and
?.?=. #are of patient with intravenous therapy restoration of health.

 Standard II# Care Plan  Measura$le Elements

The nurse caring for patients develops and updates an
individuali/ed written care plan in the patient’s record within
the prescribed time frame.
 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;

?.?. Scope of Nursing Practice as provided by
law and all relevant legislations !e.g. The
Philippine Nursing Act of @FF@ or "epublic Act
E?<>&
?.@. 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
?.. Ten !?F& 7olden "ules in 'rug Administration
?.=. #ode of -thics for Nurses
?.C. Patient ill of "ights
@. It is evident that implementation
interventions(care is delivered in a safely manner 
that minimi/es complications and life$threatening
situations.
 Standard IV# Ealuation of Care
The nurse caring for patients systematically and
continuously evaluates the patient’s progress based on the
effectiveness of nursing intervention rendered and medical
management provided.
 Measura$le Elements
?. Systematic and continuous evaluation of patient’s
 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 patient’s responses to
interventions are documented.
. 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.
of   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.
. Processes to communicate with and evaluate patients
and families about pain are evident.

 Standard VI# Medication Management   Standard VII# End&of&'ife Care

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.
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$le Elements  Measura$le Elements

?. There are written policies procedures and guidelines ?. "espect for patient’s values religion and cultural
on medication management which include but are  preferences and practices is evident.
not limited on the following; ?.?. Pastoral services are provided based on the
?.?. #arrying out physician’s medication order  spiritual beliefs of the patient and fa mily.
?.@. Transcribing and ordering ?.@. The patient’s right of self$determination
?.>. -ndorsing !especially high valuable drugs& and choices are respected and accommodated.
?.. Preparing ?.>. Advance directives 'o Not "esuscitate
?.=. 5abeling 1aiver 5iving will if any are respected.
?.C. Administering !?F 7olden "ules in 'rug ?.. Patient and family choices to donate organs and
Administration& other tissue are supported through provision of 
?.<. 'ocumenting relevant information. In accordance to statutory
?.D. 4onitoring and Storage laws rules and regulations.
?.E. -mergency 'rugs @. Assessment appropriate intervention to alleviate the
?.?F."egulated 'rugs  patient’s pain and discomfort according to wishes of 
?.??.4edication "ecall System !-)pired or   patient and family and re$assessment are evident.
%utdated 'rugs& @.?. Pain assessment intervention and
?.?@."eporting on evaluation are monitored and recorded.
@.@. Personal hygiene is rendered based on patient’s
4edication effects and adverse effects
need.
4edication error and near$miss
 

@.>. Nutritional assessment and ris*s are ?.<. Support patient and family rights
identified and nutritional needs are provided  by participating in the care decision and care
such as feeding and hydration.  process through information of the following;
@.. Interventions address patient and 4edical condition and confirmed
family’s psychosocial emotional spiritual and diagnosis and the informant
cultural
Planned care treatment outcome of care
concerns.
unanticipated outcome and participation in
>. A place is designated for the patient’s family to stay.
care decision according to wishes
. The patient and family are involved in care
management and decision. Informed consent
"efusal or discontinuance of treatment
 Standard VIII# Patient and Family Rig(ts 1ithholding life$sustaining treatments
Assessment and management of pain
The Nursing Services 'epartment has established #ompassionate care at the end$of$life
 policies processes and guidelines that respect and support Process on complaints and differences of 
 patient and family rights. opinion about patient care
Participation in clinical research
 Measura$le Elements %rgan donation and other tissues
'isclosure of information
?. There are written policies processes and guidelines @. There is evidence that nurses are *nowledgeable and
that respect and support patient and family rights supportive of patient and fa mily rights.
which include but are not limited on the following;
?.?. Prerogative to determine what III$ Standards on atient and Fami!. Education
information regarding health condition and care
is provided  Standard I# Education Assessment 
to family and under what circumstances.
?.@. "espect for patient’s personal values and beliefs The nurse assesses the educational needs of each patient
?.>. "espect the confidentiality of patient health
and family and documents these in his(her patient record.
information
?.. "espect for patient’s need for privacy !e.g.
 Measura$le Elements
during treatment procedure physical
e)amination clinical interview transport&
?.=. Protection of patient’s possessions from theft ?. There is a written evidence that the nurse assesses
or loss the educational needs of each patient and family
?.C. Protection of patient from physical assault which include but are not limited on the following;
!e.g. vulnerable patients are infants children ?.?. Patient’s and family’s beliefs and values
and ?.@. Patient’s and family’s literacy
elderly& ?.>. Patient’s and family’s educational level

?.. Patient’s and family’s language
?.=. Patient’s and family’s motivations
and emotional barriers
?.C. Patient’s physical and cognitive limitation
?.<. Patient’s 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$le Elements
?. The educational plan and programs for patient and
family are evident according to the type of patient
served and his(her learning needs.
@. The appropriate structure methods and mechanism
for education is afforded.
>. -ducation resources are available and organi/ed in
an efficient and effective manner.
. 1hen appropriate it is evident that the patient and
family are educated on topics considered high ris* to
 patients;
.?. Safe and effective use of medications and their  contact with the patient
side effects
.@. Preventing interactions between prescribed
medications and other medications !over the
counter& and food
.>. Safe and effective use of medical equipment
.. Pain management
.=. "ehabilitation techniques
.C. Treatment and diagnostic procedures
=. It is evident that standardi/ed materials and
 processes in educating patient and family on the
aforementioned topics !.? to .=& are available.
C. There is an evidence that nurses who provide
education have the sub+ect *nowledge adequate
time and communication s*ills to do so.
IV$ 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 
st
screening is initiated at the point of ?
?.>. #riteria for admitting patient or registering
out patient
?.. 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  >. It is evident that patients admitted and or transferred
health condition at the time of admission in the health care
facility.
 Measura$le Elements
?. There is an evidence that nurse screening assessment
focuses on preventive curative rehabilitative and
 palliative services and prioriti/es these according to
the patient’s health condition.
@. There is an evidence that nurse actively participated
in providing relevant information to patient and
family during the admission process which includes
 but are not limited on the following;
@.?. Proposed plan of care
@.@. -)pected outcome of care
@.>. -)pected cost of care
@.. Sufficient information to ma*e *nowledgeable
decision and
@.=. 5imit or overcome barriers such as language
cultural physical to access and in the delivery
of care
 Standard IV# Intensie and S"eciali)ed Serices
The Nursing Services 'epartment has established entry(
or transfer criteria for patients that need intensive and
speciali/ed services to meet special patient needs congruent
with those of the organi/ation.
 Measura$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.
to intensive and speciali/ed areas(units meet the
established criteria and are documented in the
 patient record.
. 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$le Elements
?. The written policies and processes on patient
continuity of care are evident and implemented
throughout all phases of patient care particularly but
are not limited in the f ollowing services;
?.?. -mergency services to nursing ward admission
?.@. Nursing ward services to diagnostic services
?.>. Nursing ward services to surgical and
non$ surgical services
?.. 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  'iet
Follo,&u"
The Nursing Services 'epartment has established
 policies and processes and guidelines on patient’s discharge
out on pass referral and follow$up congruent with those of  health professionals in the community.
the organi/ation.
 
 Measura$le Elements
?. There are written policies procedures and guidelines  
on patient’s discharge out on pass referral and  
follow$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.
. There is a referral system of patients for transfer to
other organi/ation.
=. The patient’s discharge summary is prepared by
qualified individuals recogni/ed by the organi/ation.
C. 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;
C.?. "eason for admission
C.@. Significant physical and other findings
C.>. Significant diagnosis and co$morbidities
C.. 'iagnostic and therapeutic procedures
 performed
C.=. 4edications and treatments
C.C. 4edications to be ta*en at home
C.<. #ondition of patient at the time of discharge
C.D. 6ollow$up instruction in an understandable form
and manner 
Activity
 Ne)t medical consultation
:rgent care indicators
C.E. "eferral for support services to either health care
 providers health organi/ations or agency and
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$le Elements applicable forms which include but are not limited
on the following;
?. There is a written policy procedure and guidelines ?.?. Patient’s addressograph 8 name age
on transfer of patient within and outside of the gender civil status
organi/ation. ?.@. "egistration number and or Admission
@. The guidelines and procedures include but are not number 
limited on the following; ?.>. 'ate and time of admission and discharge
@.?. Transfer is based on the patient’s needs for  ?.. 4ode of admission(transport(discharge
continuity of care. ?..?. Admitted via; ambulatory
@.@. Transfer of responsibility to another  wheelchair stretcher 
health provider or health care setting is evident. ?..@. Admitted from; home transferring
@.>. "esponsible health care provider during the hospital care facility
 patient’s transfer is identified. ?.=. Attending physician and referring physician
@.. 6ormal and informal arrangements are apparent. if any
@.=. Summary of patient’s clinical ?.C. "eligion
condition interventions !medical and nursing& ?.<. 5anguage spo*en
and continuous care rendered are written. ?.D. Advance directive
@.C. Situation when transfer is not possible is stated. ?.E. 2ealth #are Insurance
@.<. Patient’s transfer is documented.
@.D. Safe and quality medical transport services  Standard II# Clinical Data
within and outside of the organi/ation are
 provided. The nurse documents essential clinical data of each
 patient accurately and completely based on individuali/ed
V$ Standards on Nursing Documentation nursing care plan from admission to discharge in health care
facility.
 Standard I# Structural Data
 Measura$le Elements
The nurse documents structural data of each patient
accurately and completely based on applicable laws and ?. There is relevant(essential accurate and complete
regulations professional standards and institutional nursing documentation of patients’ clinical data in
requirements. all appropriate forms from admission to discharge
in health care facility which include but are not
 Measura$le Elements limited on the f ollowing;
?.?. Physical e)amination !head$to$toe&
?. There is an accurate and complete documentation ?.@. 2ealth history
of patients’ structural data in all nursing and
 

?.>. Psychological social spiritual and

economic evaluation
?.. Actual and potential health problems and AD-INISTRATION 1 -ANAGE-ENT
needs
?.=. 'iagnostic and therapeutic interventions I$ Standards on Governance and Direction
?.C. Pharmacological management
?.<. Nursing interventions  Standard I# oernance Structure
?.D. 2ealth teachings 8 patient and family
?.E. Patients’ response and outcome The Nursing Services 'epartment has governance
?.?F. Preferences and idiosyncrasies 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.
. The Nursing Services governance structure and
 processes support professional communication
clinical planning and services and policy
development.

 Standard II# oernance Res"onsi$ility and 

 Accounta$ility

The governance responsibility and accountability are
described in a written document to guide how they are to be
carried out.
 Measura$le Elements
?. The governance responsibility and accountability are
described in organi/ation’s by$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.
. There is a written document that describes how the
 performances of the governing entity are appraised
 by specific criteria.
 Standard III# Direction&Setting  and management plans into action which include;
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$le Elements
?. Those responsible for the Nursing Services
'epartment governance primarily sets its direction
 by formulating its vision mission philosophy core
values and quality ob+ectives congruent with that of  ?.
the institution and the Nursing profession.
2. The vision mission philosophy and core values are
written ! specific, measurable, attainable, reliable,
time bound, ethical and recorded & reviewed
updated widely disseminated interpreted and
operationali/ed.
 Standard IV# Strategic % +"erational Pl ans
The Nursing Services 'epartment has documented
strategic and operational plans consistent with the hospital
wide quality plan.
 Measura$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
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 conforms with the applicable statutory laws rules and
as approved by the authori/ed person(office and regulations.
monitored based on responsibility accounting.
>. -ach Nursing :nit has an individual budget plan
 periodically monitored for variances.  Measura$le Elements
. The medical supplies materials and equipment
recommended by professional organi/ations and ?. Those responsible for governance formulate policies
authoritative sources are obtained and appropriately and procedures to serve as guidelines for those
used. confronted by ethico$moral dilemmas in patient care.
@. Those responsible for governance ensure compliance
 Standard VI# Policies % Procedures Deelo"ment  with the applicable statutory laws regulations and
standards.
The policies and procedures of the Nursing Services >. The Nursing Services 'epartment has a written
'epartment that reflect Standards of Nursing #ode of -thical ehavior which observes the rights
Administration Nursing Practice on Patient #are are and safety of patients and health care providers.
developed and communicated to serve as operational
guidelines.  Standard VIII# Professional % +rgani)ational 
 Inolement 
 Measura$le Elements
The administrator of the Nursing Services 'epartment
?. Those responsible for governance develop and actively participates and collaborates with leaders within the
implement policies and procedures based on organi/ation and professional associations for continuous
established Standards of Nursing Administration and quality improvement of nursing services.
 Nursing Service on Patient #are.
@. An updated manual of Nursing Services policies and  Measura$le Elements
 procedures e)ists and provides clear directive for 
nursing personnel at different levels on the scope ?. Those responsible for Nursing Services 'epartment
and limitations of their f unctions and responsibilities governance initiate and maintain formal
to patient care. liaison(lin*age with other departments(sections of 
the institution and professional associations and
 Standard VII# Et(ico / Moral % 'egal Accounta$ili ties agencies pertinent to nursing standards and
 practices professional and interprofessional
The Nursing Services 'epartment has an established relationships and other related endeavors.
framewor* for ethico$moral and legal management to
support the ethical decision$ma*ing in the clinical areas and

II$ Standards on /uman Resource -anagement
 Standard I# Administrator of Nur sing 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  !7S#&.
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   Standard II2  Staffing Plan
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 master’s 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.
?.. 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.
?.=. 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 7eneral Staff #ourse
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.
 

The Nursing Services 'epartment has a staffing plan development of system and processes for 
that identify the number type and desired qualification of  recruitment selection hiring appointment and
nursing services staff which is written reviewed and updated  promotion of nursing service personnel in
on an ongoing basis. 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
 Measura$le Elements  personnel and are uniformly implemented.
>. Staff recruitment selection hiring and appointment
?. Those responsible for Nursing Services governance are based on institutional patients’ needs and
develop a staffing plan that identify the number type applicant qualification.
and desired qualification !education s*ills and
e)perience& of Nursing Services staff reviewed and  Standard IV# Credentialing 
updated on an ongoing basis.
@. Those responsible for Nursing Services governance The Nursing Services 'epartment has an effective
consider the organi/ation’s mission type of services  process for gathering verifying and evaluating the nursing
level and modality of care patients’ mi) staff and staff credentials.
s*ills mi) and other factors affecting the pro+ection
of staffing needs.  Measura$le Elements
>. The staffing plan is defined in writing and meets the
needs of the patients(population served and scope of  ?. Those responsible for Nursing Services governance
services. develop an effective process for gathering verifying
and evaluating the nursing staff credentials
 Standard III# Recruitment* Selection* Hiring and  !licensure education training wor* e)perience& and
 A""ointment  other pertinent requirements.
@. There is evidence of standardi/ed procedure to
The Nursing Services 'epartment has an established gather the credentials of all nursing staff.
system and processes for recruitment selection hiring >. The licensure education training and wor* 
appointment and promotion of human resources in e)periences of nursing personnel are documented
accordance with the statutory laws and regulations and the and updated.
institutional policies and procedures.
 Standard V# Staff Placement 
 Measura$le Elements
The Nursing Services 'epartment has defined criteria
?. Those responsible for the Nursing Services and processes to ensure the clinical staff *nowledge and
governance actively participate(collaborate in the 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$le Elements
?. Those responsible for Nursing Services governance  Standard VII# Staff Deelo"ment 
develop and define the criteria !core competencies&
and processes to match the clinical staff *nowledge The Nursing Services 'epartment has an established
and s*ills with the patients’ needs. staff development program for all nursing personnel to
@. There are written core competencies required for  encourage and promote continuing personal and professional
every +ob position in the Nursing Services growth and development.
organi/ation to ensure that the staff s*ills are
consistent with the patients’ needs.  Measura$le Elements
>. Staff placement(assignment is based on patient
needs available resources and staff competencies. ?. Those responsible for Nursing Services governance
design and implement staff development programs
 Standard VI# Staff 0o$ Descri"tion
for nursing personnel at all levels based on training
needs analyses.
The Nursing Services 'epartment has +ob description for  @. There is evidence of staff development programs for 
each position classification of Nursing personnel which all nursing personnel throughout the year which
specifies duties and responsibilities based on established include;
standards of performance. a. %rientation program for newly hired and
 promoted staff to the organi/ation
 Measura$le Elements department(unit to which they are assigned as
well as their specific +ob responsibilities.
?. There is a written 0ob 'escription for each position  b. Safety program to protect the patient staff and
classification of Nursing Services personnel which  property.
specifies; c. #ontinuing education training and opportunities
?.?. 'uties and responsibilities for professional advancement of staff member to
?.@. Accountability enhance their *nowledge and s*ills.
?.>. 6unctional relationship d. #areer counseling and career 
?.. 9ualification and e)perience required advancement(ladder.
>. "esources are available to implement the staff 
development program such as;
 

>.?. Space and facilities @. Those responsible for governance actively

>.@. -ducational resources  participate in space planning as well as medical
>.>. #linical and clerical staff  equipment and supplies procurement.
>.. Audiovisual equipment >. Those responsible for governance plan and budget
>.=. "esource spea*ers for upgrading or replacing *ey components based on
facility inspection findings.

. Policies and procedures on continuing education  Standard II2  Enironmental Safety

staff attendance to staff development programs are
evident. The Nursing Services 'epartment actively participates
=. "ecords of staff development program are in the planning implementation and evaluation of hospital 8 
maintained which include; wide programs to provide a safe and secure physical
=.?. Title of the program environment.
=.@. %b+ectives of the program
=.>. Program design and content  Measura$le Elements
=.. -valuation of the attendees
=.=. -ffectiveness of the program ?. There is a written and up$to$date plan
=.C. 5ist of attendees(participants implementation and evaluation of  
 programs(activities to manage the ris*s within the
III$ Standards on Faci!it. -anagement 1 Environment environment which includes but is not limited on the
Safet. following;
?.?. Safety and Security
 Standard I2 Facility Planning 
There is an e)isting provision for the
identification of patient and their families
6or efficient and effective delivery of nursing care and visitors staff and others.
services the Nursing Services 'epartment provides a safe
4onitoring mechanism of all ris* areas is
functional and supportive facility to patients and their 
in place and *ept secure to patient from
families staff and visitors aligned with that of the
unauthori/ed access or use tampering
organi/ation’s master plan.
destruction or loss. !e.g. 4edication
"oom&
 Measura$le Elements
?.@. 2a/ardous 4aterials and 1aste
?. Those responsible for governance comply with
There is a current list of ha/ardous
relevant laws regulations and other requirements
materials and waste to safely control them
that are applicable.
!e.g. chemotherapeutic agents chemicals
radio$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.
?.>. 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  implemented.
 planning and improvement.
?.. :tilities
Potable water electrical power and
medical gases are available @ hours a
day seven !<& days a wee*.
A written emergency processes is in place
in the event of water interruption or  control practices.
contamination electrical failure or 
interruption and medical gases
unavailability.
4onitoring of utilities is evident for  The Nursing Services 'epartment ensures education and
 purposes of planning and improvement.
?.=. -mergencies
An emergency management plan and
 processes are evident to li*ely community(
institutional emergencies epidemics and
disasters.
?.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
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
 Standard III2  Staff Education
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 -ducational materials and methods in an
on facility management and environmental safety understandable format and language
 programs.
@. There is an evidence that the staff can describe and ?.>. Nursing Personnel
demonstrate their role in the aforementioned safety  Nursing endorsement in between wor* 
 programs. shifts
>. There is an evidence of staff training to operate  Nursing documentation
medical equipment appropriate to their +ob
"eferral
description.
 Nursing Service Philosophy 3ision
4ission #ore 3alues
VI$ Standards on Communication -anagement
Policies Procedures 7uidelines
Standards
 Standard I2 Communication of Information
4emorandum #ircular 'irectives
Activities
The Nursing Services 'epartment has efficient and
effective system of communication with the community to ?.. %ther 2ealth Professionals !clinical and non$
 patients and their families nursing personnel and other 
clinical staff&
health professionals throughout the organi/ation.
Patient care and response to care !referral&
Patient clinical data !diagnostic
 Measura$le Elements
e)aminations and therapeutic procedures&
?. There is efficient and effective system of  #ircular 
communication that e)ist which include but are not
 Standard II2  Patient Clinical Record 
limited on the following;
?.?. #ommunity
The Nursing Services 'epartment has established
Patient(nursing care services
 policies procedures and guidelines on patient clinical record.
2ealth programs
Process to access care  Measura$le Elements

?.@. Patients and 6amilies
Patient health condition
#are provided to patient
Patient’s response to care
Patient(nursing care services available
Alternative sources of care and services
Process to access care
?. 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 ?.??.9uality Improvement Program and other 
unauthori/ed access and use Pro+ects
?.. 'ata Integrity ?.?@.4anuals of the %rgani/ation
Protection from tampering 9uality System
?.=. :se and monitoring of standardi/ed Infection #ontrol
abbreviations symbols procedure codes and -mergency Preparedness
definitions
-mployees’ 4anual
?.C. "etention period of records !as prescribed
 by law and institutional policy& %thers
@. There is written policy or protocol in developing and
maintaining policies and procedure which include
 Standard III2  Administratie Record 
 but are not limited on the following;
@.?. "eview and approval of all policies and
The Nursing Services 'epartment has established
 procedures before implementation
 policies or protocol in *eeping and maintaining its
@.@. Process and frequency of review and continued
administrative record and defining the requirements for  approval of policies and procedures
developing and maintaining policies and procedures. @.>. #ontrol that only current policy and procedures
are implemented
 Measura$le Elements @.. Identification of charges in policy and
 procedures
?. There is a written policy or protocol in *eeping and @.=. "etention of obsolete policies and procedures
maintaining Nursing Services 'epartment @.C. "eferences originating outside the organi/ation
administrative records which include but are not @.<. Trac*ing of policy and procedures in circulation
limited on the following; !e.g. title date of issue authori/ed person&
?.?. %rgani/ation and Nursing Services 'epartment
Policies Procedures 7uidelines V$ Standards on 0ua!it. Im"rovement
?.@. Standards
?.>. 4aster Staffing Plan  Standard I2  'eaders(i" and Staff Education
?.. Staffing Pattern
?.=. #ensus of Patients and 'iseases The Nursing Services 'epartment has continuous quality
?.C. ed #apacity and %ccupancy "ate improvement on patient and staff safety programs through
?.<. udget Plan monitoring and analy/ing variation of data and undesirable
?.D. Staff 'evelopment Programs trends of events.
?.E. #ommittees Nursing and the %rgani/ation
?.?F.4inutes of 4eeting Nursing Services  Measura$le Elements
'epartment

?. 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.
. There is a qualified trainer who provides the training
and staff participation as part of their regular wor*  indicators to monitor the clinical and managerial structure
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$le Elements
?. There is written plan or policy or document of a well
designed new processes or modified e)isting
 processes consistent with current practice
guidelines clinical standards scientific literature
and other relevant evidence 8 based information.
!e.g. 4edication safety clinical pathway&
@. There is an e)isting plan and program to reduce the
ris* of community(hospital acquired infectious for 
 patients and health care associated infections for 
staff.
>. There is an evidence that the quality
improvement(processes and safety programs are
approved by governance implemented and
monitored for consistent use and effectiveness.
Standard III2 !uality Monitoring* Analysis %
 Im"lementation
The Nursing Services 'epartment has established *ey
processes and results and data are aggregated analy/ed and
transformed to useful information.
Measura$le Elements
?. There is a clinical monitoring that e)ists but is not
limited on the following;
?.?. #linical research
?.@. Nursing documentation
?.>. 4edication error 
?.. 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&
@.. 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.
. 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  services.
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
Continuit. of Care  8 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 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 patient’s 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  a!!iative Services 6 are treatments and support services
establishing policy maintaining quality of care and
 providing for organi/ation management and planning. %ther  illness.
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  in meeting specified goals and ob+ectives. It is based on data
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.
intended to alleviate pain and suffering rather than to cure
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 patient’s care
needs lists the strategy to meet those needs documents
treatment goals and ob+ectives outlines the criteria for 
ending intervention and documents the individual’s progress
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/ation’s 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  REFERENCES
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  #ommittee on the "evision of the 2ospital Nursing Service
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.
Association of Nursing Service Administrators of the
Philippines Inc. !@FF?& Standards of Nursing Services
Association of Nursing Service Administrators of the
Philippines Inc. and Philippine Nurses Association Inc.
!?EEE&. Standards of Safe Nursing Practice
Administrative 4anual !?EEF&. The Administration of 
2ospital Nursing Services in Philippine 'epartment of 
st
2ealth ? -dition
0oint #ommission International !@FFD&. Accreditation Standards
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for 2ospitals > -dition Printed in :SA =>@?
0oint #ommission International !@FF&. #redentialing -dition
Printed in :SA =>@?
0oint #ommission International !@FF&. 2uman "esources for 
2ospitals -dition Printed in :SA =>@?
 Noe 2ollenbac* 7erhart 1right !@FF&. 6undamental of 
2uman "esource 4anagement 4c7raw$2ill #o. Inc. New
or* 
"epublic Act E?<> or The Philippine Nursing Act of ?EE?
"epublic of the Philippines 4etro 4anila
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"obbins S. #oulter 4 !@FF&. 4anagement < -dition
Pearson -ducation South Asia PT- 5T'.
 

"owland 2 J "owland  !?EDF&. Nursing Administration

2andboo* Aspen Publication

Tomey A.4 !@FF&. 7uide to Nursing 4anagement and

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1eber 0 !@FFC&. Nurse’s 2andboo* of 2ealth Assessment =
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