STANDARDS FOR NURSING EXCELLENCE

COMMAND HOSPITAL (NC) UDHAMPUR

FOR

HOSPITALS AND HEALTHCARE

PROVIDERS
 FOREWO
RD

Nursing services are an integral part of the clinical services of any health care organization.
The aim of nursing services is to provide comprehensive nursing care in terms of health
promotion, prevention of diseases and therapeutic nursing care to the patients in a HCO as
well as to the community.

Standards are pre requisite for the promotion of safe, effective, competent and ethical nursing
care. We profess that we excise all the standards to meet Nursing excellence. We started this
by taking baby steps of first creating a policy to execute the standards. This was followed by
training and a continuing nursing education in Nursing excellence and standards.

Apart from serving as a frame work for evaluation of the quality of nursing services
rendered, this book will provide guidelines to assist nurses in decision making and will
support the nursing efforts by outlining the professional expectation from the nursing
services.
 TABLE OF
CONTENTS
Chapter No Particulars Page No.
.
Chapter:1 Nursing Resource Management (NRM)
Chapter:2 Nursing Care of Patient (NCP)
Chapter:3 Management of Medication (MOM)
Chapter:4 Education, Communication and Guidance (ECG)
Chapter:5 Infection Control Practices (ICP)
Chapter:6 Empowerment and Governance (EG)
Chapter:7 Nursing Quality Indicators (NQI)
Glossary
 NURSING RESOURCE MANAGEMENT

Standard

Sr No Objective Elements Compliance Remarks

Command Hospital
Northern Command
a. Nursing resource planning supports the
organization’s current and future ability to
meet the care, treatment and service needs
of the patient.
The organization maintains an adequate
b.
number and mix of nursing staff to meet
the care, treatment and service needs of the
patient.
c. The person heading the nursing service has
requisite and appropriate qualifications.
d. The person heading the nursing service has
requisite and appropriate experience.
e. The required job specification and job
description are defined for each category of
nursing staff.

NRM.1. The organization has a documented system of nursing resource planning.

Sr.N

Objective Elements CHNC Remark(s)

a. Nursing resource Yes, Compliant.
planning supports the Proper planning of man power resource
organization‟s current and management is projected according to
future ability to meet the care, the requirement periodically.
treatment and service needs of
the patient.
b. The organization Yes, Compliant.
maintains an adequate number
and mix of nursing staff to
meet the care, treatment
and service needs of the
patient.

c. The person heading the Yes, Compliant. The principal Matron

nursing service has requisite has adequate qualifications for her post
and appropriate qualifications.

d. The person heading the Yes, Compliant .The nursing service is .

nursing service has requisite headed by the principal Matron who
and appropriate experience. was more than 32 yrs in administration

e. The required job Yes. Compliant. Job description is .

specification and job specified and designed by the nursing
description are defined for leaders. .
each category of nursing staff.

Standard

NRM.2. The organization has structures and processes for induction and for
enhancing the transition of novices to competent nursing professionals.

Sr.No Objective CHNC Remark(s)

a. Nursing shift plans based upon Yes,Compliant.The .
timings of shift, day or week shall nursing
identify and depute nursing Professionals d o i n g
professionals to various areas based on the shift at night
their skills and competencies. are having skills and
competencies that
enable her to
independently monitor
b. Training need shall be identified Yes, Compliant .Weekly .
Training is conducted to
on a continual basis by the senior
upgrade the knowledge
nursing professionals as well as the and skills of Nursing
professionals
Clinical Heads as appropriate.
c. Required competency parameters Yes, Compliant. .
shall be evaluated by such senior
nursing professionals and the clinical
and support service Heads and shall be
recorded in the training records as in
NRM 2.

Standard
NRM.3. The organization has processes in place for induction training, In-service
education and Continuous Nursing Education (CNE) programmes and for
documentation of the same in the personal files.
Sr.No Objective Elements CHNC Remark(s)
a. Every nurse entering the Yes, Compliant.Induction
organization is provided induction training of newly inducted
training. nursing professionals is in place
in all hospitals.
Training in department is done as
a part of on the job training
b. A documented training and Yes, Compliant.
development policy exists for the
staff.
c. The organization maintains Yes, Compliant.
records of training.

d. Nursing professionals shall Yes, Compliant.

receive adequate training when there is
a change in job responsibilities or
when new equipment is introduced.

e. All nursing staff shall be trained to Yes, Compliant. As per appendix

shown
provide BLS. Nursing
professionals working in intensive
care/high dependency units shall
undergo training in ACLS or PALS
or NALS as applicable.

Standard
NRM.4. There is a process for credentialing and privileging of nursing professionals,
permitted to provide patient care without supervision.

Sr.No Objective Elements CHNC Remark(s)

a. The education, registration, Yes, Compliant. Updation is
training and experience of nursing done after acquisition of new
staff is recorded and updated skills and/or qualification after
periodically. verifying from the various
b. Nursing staff permitted by law, Yes, Compliant.
documents All the nursing
and certificates is .
regulation and the organization to Officers inducted in Army are
provide patient care without registered nurse as per guidelines
supervision are identified. of INC. Every year along with
All such information pertaining to appraisal, registration is verified
the nursing staff is appropriately of each Nursing Professional. In
verified when possible. educational Institute during
Inspection by regulatory bodies
such documents are verified.
d. Nursing staff are granted Yes, Compliant. The
organization
privileges in consonance with their
lay down parameters for
qualification, training, experience and
identifying nursing professionals
registration.
according to their credentials.e.g
Infection Control Nurse is
e. The requisite services to be Yes, Compliant. .
provided by the nursing staff are .
known to them as well as the various
departments/units of the organization.

f. Nursing professionals care for Yes, Compliant. New staff

patients as per their privileging. members
are under the
proctorship till independent

Standard
 NRM.5. An appraisal system for evaluating the performance of nursing staff exists
as an integral part of the nursing resource management process.
Sr.No Objective Elements CHNC Remark(s)
a. A recorded performance Yes, Compliant.
appraisal system exists in the
organization for nursing

b. professionals.
The nursing professionals Yes, Compliant.
are made aware of the system
of appraisal at the time of
induction.

c. Performance isevaluated Yes, Compliant. Attached

based on the pre- determined as per appendix
criteria.

d. Performance appraisal is Yes, Compliant.

Performance appraisal is
carried out at pre-defined
carried out every year
intervals and is recorded.

Standard

NRM.6. There is a provision for acknowledging outstanding performances/

contributions of nursing professionals.
 Sr.No Objective Elements Interpretation Remark(s)

a. Patients, families and staff shall Yes, Compliant

be encouraged to report positive
feedback about nursing care delivered
in relevant areas.

b. Nursing staff with managerial Yes, Compliant .

responsibilities shall ensure that soft
skills in nursing, qualities of
leadership and professional
competence are duly reported to
higher authorities.

Standard

NRM.7. There is an established process in place to identify and manage problems

related to incompetent, unsafe or unprofessional conduct.

Sr.No Objective Elements CHNC Remark(s)

 a. The process shall include daily Yes, Compliant
monitoring of appearance and
ability to impart nursing care.

b. The process shall include analysis Yes, Compliant

of all complaints pertaining to nursing
services specifically addressing
individual nursing staff.

c. The disciplinary policy and . Yes, Compliant

procedure is based on the
principles of natural justice.

Standard

NRM.8. The organization demonstrates workplace safety for nursing professionals

(including change rooms, washrooms & dining facilities).

Sr.No Objective Elements CHNC Remark(s)

 a. Management provides resources Yes, Compliant .
related to workplace safety for
nursing professionals.
b. Management shall ensure that Yes, Compliant. There .
are women cell in our
there is a mechanism whereby any
hospital which looks
safety related issues are duly reported. after the safety issues of
the women.

c. Management shall endeavour to Yes, Compliant. There

is a Committee headed
promote a culture of reporting of
by the Senior medical
safety related issues such that there is officer who looks after
the workplace safety
no victimization.
of women from
sexual harassments

d. A record of corrective and Yes, Compliant

preventive actions shall be maintained
wherever appropriate, with due
consideration given to anonymity.

Standard

NRM.9. The organization has a documented and established grievance handling

system.

Sr.No Objective Elements CHNC Remark(s)

a. The organization has a well- Yes, Compliant .
defined process for handling
nurse (s) grievances.
b. The nursing professionals are Yes, Compliant
educated about the mechanisms
available for addressing grievances.

c. The head of the nursing service . Yes, Compliant .

protects nurse (s) rights.
d. The nursing professionals are Yes, Compliant
educated about their rights.
 CHAPTER: 2

NURSING CARE OF PATIENT

Summary of Standard

NCP.1. Nursing manual shall be established and reviewed periodically as defined by

the HCO.
NCP.2. The initial assessment shall be done by the nursing professionals in
predetermined format at prescribed time and/or as per the needs of the patients.

NCP.3. The reassessment shall be done by the nursing professionals in

predetermined format at prescribed time.
NCP.4. For provision of nursing care, appropriate number of nursing professionals
shall be maintained as per workload.
NCP.5. The nursing care planned and provided by the nursing professionals is
recorded.
NCP.6. The nursing care is individualized to address the needs of patient and family.
NCP.7. Information is exchanged and documented during each staffing shift,
between shifts, and during transfers between units/departments.
NCP.8. There shall be established policies and protocols for vascular access
devices. (VADs)
NCP.9. The nursing care of inpatients shall be supervised by senior nursing
professionals.
NCP.10. The nursing care of vulnerable patients (elderly, children, physically and/or
mentally challenged) shall be supervised by senior nursing professionals.
NCP.11. The nursing care of patients under restraints (physical and/or chemical) shall
be supervised by senior nursing professionals.
NCP.12. Appropriate pain management practices shall be supervised by senior
nursing professionals.
NCP.13. Appropriate end of life care shall be provided to patients needing the same
by the nursing professionals.

Standards and Objective Elements

Standard
NCP.1. A Nursing Manual shall be established and reviewed periodically as defined
by HCO

Sr.No Objective Elements CHNC Remark(s)

a. Nursing manual shall include Yes, Compliant .
standard operating procedures and
guidelines for nursing care in all
settings.

b. Nursing manual shall also include Yes, Compliant .

policy on nursing station
management.
c. Nursing manual shall contain a Yes, Compliant .
master list of various forms and
formats used by nursing professionals.

d. Nursing manual shall be available . Yes, Compliant

for and followed by the nursing
professionals uniformly.
e. Nursing manual shall be reviewed Yes, Compliant
and updated regularly at least
once in annually.

Standard

NCP.2. The initial assessment shall be done by the nursing professionals in

predetermined format at prescribed time and/or as per the needs of the
patients.
 Sr.No Objective Elements CHNC Remark(s)
a. Initial assessment of in-patients Yes, Compliant .
includes nursing assessment done and
documented at the time of admission.

b. Initial assessment includes Yes, Compliant

assessment of actual and
potential needs & problems.

c. The initial nursing assessment Yes, Compliant, .

results in a documented nursing care Attached as per
appendix
plan.
d. The care documentation must Yes, Compliant
include preventive aspects of the care
where appropriate.

Standard

NCP.3. The reassessment shall be done by the nursing professionals in a

predetermined format at prescribed time.

Sr.No Objective Elements Interpretation Remark(s)

a. Patients are reassessed at Yes, Compliant
appropriate intervals.
 b. Patients are reassessed at the Yes, Compliant. Attach
as transfer checklist
time of receiving and transferring
from one unit to another.

c. Patients are also reassessed Yes, Compliant

before and after shifting for
investigations.
d. Nursing care plan is modified Yes, Compliant. critical .
care units have different
when emergency situations arise.
assessment format
e. Nursing professionals evaluate Yes, Compliant .
Outcomes using reassessment and
revise action plans as needed.

Standard

NCP.4. For provision of nursing care, appropriate number of nursing professionals

shall be maintained as per workload.
Sr.No Objective Elements CHNC Remark(s)
a. Nurse patient ratio is planned and Yes, Compliant
provided based on the scope of the
unit.

b. Nurse patient ratio is monitored in Yes, Compliant

every shift by the designated
senior nursing professionals.
c. Patient condition and nurse‟s Yes, Compliant
competency shall be considered while
assigning nursing professionals to
patient care in each shift.
Standard

NCP.5. The nursing care planned and provided by the nursing professionals is
recorded.

Sr.No Objective Elements CHNC Remark(s)

a. Nursing professionals document Yes, Compliant
assessment, nursing activities, and
care outcomes in accurate and
timely, manner.
b. Documented information shall be Yes, Compliant. done in evening .
and morning rounds
checked and supervised by the senior
nursing professionals wherever
appropriate.
c. There shall be a consistent Yes, Compliant .
pattern adopted by the nursing service
for documentation of nursing care.

d. Adequate supervision is ensured Yes, Compliant. Senior nursing .

for the junior staff after delegating the member in the department is
responsibilities. totally accountable and answerable
for all the activities of the nursing

Standard

NCP.6. The nursing care is individualized to address the needs of patient and Family.
 Sr.No Objective Elements CHNC Remark(s)
a. Nursing protocols are developed Yes .
Compliant.Different
by nursing professionals based on
scales of measurement
current best practices and shall focus is used
on patient safety.
b. Assignment of patients for nursing Yes, Compliant
.
care is based on patient needs to
maximize the outcome.
c. Nurse use patient specific Yes, Compliant
.
sensitive communication and
interactive techniques to individualize
the care.
d. Care of patients is coordinated in Yes, Compliant
all care settings within the
organization.

Standard

NCP.7. Information i s e x c h a n g e d and documented during each staffing shift,

between shifts, and during transfers between units/departments.

Sr.No Objective Elements Interpretation Remark(s)

 a. Documented information shall be Yes, Compliant
Clearly dated, timed and signed by the
assigned nurse and endorsed by the
senior nursing staff at every shift.

b. Transfers between departments/ Yes, Compliant

units are done in a safe manner.

Standard
NCP.8. There shall be established policies and protocols for vascular access
devices. (VADs).

Sr.No Objective Elements Interpretation Remark(s)

 a. There shall be established Yes, Compliant
.
policies and protocols for vascular
access devices.

b. The nurse shall select the Yes, Compliant

appropriate type of catheter (peripheral
or central) to meet the patient‟s
vascular access needs.

c. The catheter selected shall be of Yes, Compliant

the appropriate gauge and length with
the fewest number of lumen and shall
be the least invasive device needed to
accommodate and manage the
prescribed therapy.

d. The nurse shall not alter the Yes, Compliant

vascular device outside the
manufacturer‟s direction for use.
e. Vascular access bundle care (for Yes, Compliant
prevention of complications)
should be followed.

Standard

NCP.9. The nursing care of inpatients shall be supervised by senior nursing

professionals.
Sr.No Objective Elements CHNC Remark
(s)
 a. A senior suitably experienced Yes, Compliant .
nursing professional should guide and supervise the
nursing professionals in each shift in each department.

b. Senior nursing professionals are Yes, Compliant .

responsible for the implementation of the policy, protocol
and procedures of the respective areas.
c. The scope of services for senior Yes, Compliant .
nursing professionals includes supervision and monitoring
of all nursing activities related to patient safety, quality of
nursing care rendered and turnaround time.

d. The nursing professionals should Yes, Compliant. .

ensure availability of patients reports in their reports collected
respective records. are endorsed in
e. Nursing professionals seek chartsCompliant
Yes,
additional knowledge and assistance as needed, in a timely
manner.
f. Nursing professionals recognize Yes, Compliant .
any limitations to safe, competent, and ethical care
and report
concerns and consult and/or
initiate appropriate changes as necessary.

g. Nursing professionals evaluate, Yes, Compliant. .

Hand hygiene study
disseminate, and support the integration of evidence based
was incorporated in
practice findings into practice. all wards. Attached
as per appendix

Standard

NCP.10. The nursing care of vulnerable patients (elderly, children, physically and/or
mentally challenged) shall be supervised by senior nursing professionals.

Sr.No Objective Elements CHNC Remark(s)

 a. There are protocols governing Yes, Compliant .
care of vulnerable patient.
b. The nursing staffs are trained to Yes, Compliant .
care for vulnerable patient.
c. All vulnerable patients are Yes, Compliant
identified as per HCO policy and then
assessed and reassessed more
frequently at periodic intervals.

d. Nursing professionals monitor Yes, Compliant .

vulnerable patients‟ closely
participating with the family whenever
required.

Standard

NCP.11. The nursing care of patients under restraints (physical and/or chemical) shall be
supervised by senior nursing professionals.

Sr.No Objective Elements CHNC Remark(s)

 a. These include both physical and Yes, Compliant
.
chemical restraint measures.
b. These patients are more Yes, Compliant. Every
2hrly or as and when .
frequently monitored.
required
c. Staff receives training and Yes, Compliant
periodic updating in control and
management of restraint techniques.

Standard

NCP.12. Appropriate p a i n m a n a g e m e n t p r a c t i c e s s h a l l be supervised by

senior nursing professionals.
Sr.No Objective Elements CHNC Remark(s)
 a. All patients screened for pain at Yes, Compliant .
the time of admission and
reassessment of pain is done for those
patients who require pain
management.
b. Nursing professionals are trained Yes, Compliant
to identify level of pain in various
categories of patients and document
the same.
c. Nursing professionals shall Yes, Compliant
provide care both
pharmacological and non-
pharmacological care based on the
hospital policy.

d. The organization respects and Yes, Compliant

supports nursing management of pain
for such patients.
e. The nursing professionals Yes, Compliant
educate the patient and their
family on various pain management
techniques wherever appropriate.

Standard

NCP.13. Appropriate end of life care shall be provided to patients needing the same
by the nursing professionals.

Sr.No Objective Elements CHNC Remark(s)

a. Nursing professionals are aware Yes, Compliant. .
of end of life care policy of the
organization.

b. MOM.1. Indenting
Nursing of requiredshall
professionals medication
Yes,and stores will
Compliant. be done and supervised
Social
by and spiritual
provide care to meet the unique end of
nursing staff made responsibleneedsfor this function.
of the Storage of medication in
family need
life care needs of the patient and
the wards and other therapeutic areas shall be supervised by responsible
is considered
family.
nursing professionals.
MOM.2. The dispensing, administration and accounting of medicines shall be carried
c. Symptomatic
out by the treatment is
concerned personnel Yes,
andCompliant
should be appropriately supervised
.
provided by the nursing
by senior nursing staff.
professionals
for allThe
MOM.3. endmonitoring
of life care patients with
of patients after medication administration is supervised by
specialresponsible
emphasis on alleviating pain
personnel.
and The
MOM.4. helping
nursingthem to
professionals cope
must report near misses, medication errors
and
psychologically
d adverse
Nursing drug are
professionals events as per
educated and the
Yes,policy of the HCO for analysis by the
Compliant
periodically trained on
appropriate end predefined
staff of life care and identified by the HCO. Feedback is

provided to staff which includes the results of analysis and recommended

preventive measures for implementation by the nursing staff wherever
appropriate.
MOM.5. The organization shall ensure that it has a policy on verbal orders which will
be applicable to doctors, nursing professionals and technicians uniformly.

CHAPTER: 3
MANAGEMENT OF MEDICATION

Summary of standards
Standard

MOM.1. Indenting of required medication and stores will be done and supervised by
nursing staff made responsible for this function. Storage of medication in the wards and other
therapeutic areas shall be supervised by responsible
nursing professionals.

Sr.No Objective Elements CHNC Remark(s)

a. Medication will be indented as per Yes, Compliant
HCO policy on indenting
medicines.
b. Medications are stored in a clean, Yes, Compliant
safe and secure environment; and
incorporating manufacturer‟s
recommendation(s).

c. Sound inventory control practices Yes, Compliant

guide storage of the medications.

d. Sound-alike and look-alike Yes, Compliant.

attached As Per
medications are identified and
appendix Policy
stored separately.
e. The list of emergency medications Yes, Compliant
is defined and is stored in a
uniform manner.
f. Emergency medications are Yes, Compliant
available all the time.

g. Emergency medications are Yes, Compliant. An

inventory check is done
replenished in a timely manner
at least daily
when used.

Standard
MOM.2. The dispensing, administration and accounting of medicines shall be carried out by
the concerned personnel and should be appropriately supervised by
senior nursing staff.

Sr.No Objective Elements CHNC Remark(s)

a. Nursing professionals are familiar Yes, Compliant .
with the medications being used for
their patients.

b. Prepared medication is labelled Yes, Compliant

Yes, Compliant
prior to preparation of a second
drug.
c. Patient is identified prior to Yes, Compliant. Identification shall
be done by unique identification
administration.
number (e.g. service number, etc.)
and/or name
d. Medication is verified from the Yes, Compliant
order prior to administration.

e. Dosage is verified from the order Yes, Compliant

prior to administration.
f. Route is verified from the order Yes, Compliant. Documented in
case sheet of the patient
prior to administration.

g. Timing is verified from the order Yes, Compliant

prior to administration.

h. Patient is monitored during the Yes, Compliant

administration of blood and blood
products, chemotherapy and other
invasive procedure.
I. Medication administration is Yes, Compliant. As per Appendix
I/O Chart
recorded.

Standard
MOM.3. The monitoring of patients after medication administration is supervised by
responsible personnel.
Sr.No Objective Elements CHNC Remark(s)
a. Monitoring of patients shall be Yes, Compliant
done after medication
administration.

b. Monitoring of patients shall be Yes, Compliant .

done after transfusion of blood and
blood products.
c. Monitoring of patients shall be NA .
done after chemotherapy.
d. Monitoring of patients shall be Yes, Compliant
done in all post-operative cases or
where invasive procedures are carried
out.
Standard

MOM.4. The nursing professionals must report near misses, medication errors and
adverse drug events as per the policy of the HCO for analysis by the appropriate staff
predefined and identified by the HCO. Feedback is provided to staff which includes the results
of analysis and recommended preventive
measures for implementation by the nursing staff wherever appropriate.

Sr.No Objective Elements CHNC Remark(s)

a. A system shall exist to capture Yes, Compliant.
Adverse book report. .
near miss, medication error and
adverse drug reactions.

b. These are reported within a Yes, Compliant

specified time frame.
c. They are collected and analysed Yes, Compliant
by appropriately trained
personnel.
d. Corrective and/or preventive Yes, Compliant
action(s) are taken based on the
analysis where appropriate.

Standard
MOM.5. The organization shall ensure that it has a policy on verbal orders which will be
applicable to doctors, nursing professionals and technicians uniformly.
Sr.No Objective Elements Interpretation Remark(s)
a. The organization shall have a Yes, Compliant
policy to address verbal orders.

b. The policy shall address who can Yes,

Compliant .Attached as
give verbal orders and how these
per appendix
orders will be validated.
c. Organization should have Yes,
Compliant. .Attached as
approved list of drugs which can be
per appendix
ordered verbally.
d. No verbal orders shall be followed Yes, Compliant .
except in case of emergency, or as
defined by the organisation

e Where verbal orders are given, Yes, Compliant

ratification shall be done at the earliest
and not later than 24 hrs

CHAPTER: 4

EDUCATION, COMMUNICATION AND GUIDANCE

Summary of standard

ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.
ECG.2. Nursing professionals shall maintain confidentiality of all patient information.
ECG.3. Nursing professionals communicate with patient, family and relevant team
members to reflect continuity of care as and when required.
ECG.4. Patient and family are educated where essential and in case of any change
in nursing care plan.
Standard

ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.

Sr.No Objective Elements CHNC Remark(s)

a. There is documented evidence of Yes, Compliant. .
communication skills training to
nursing staff to meet the patient‟s
specific needs.
b. The communication needs of Yes, Compliant .
patients who speak different language
than the care givers is addressed.

c. Training is imparted to address Yes, Compliant .

the patient‟s needs with impaired
communication.
d. Communication skill shall be Yes, Compliant .
improved periodically.

Standard
ECG.2. Nursing professionals are aware of their responsibility in protecting patient
rights.

Sr.No Objective Elements CHNC Remark(s)

a. The nursing professionals are Yes, Compliant .
aware of patient rights.
b. Nursing professionals maintain Yes, Compliant.
the confidentiality of patients
information.
c. Nursing professionals maintain Yes, Compliant
privacy of the patients during
care.

d. The nursing professionals support Yes, Compliant .

individual patient and family beliefs,
values and customs and involve the
patient and family in decision making
processes.
Standard

ECG.3. Nursing professionals communicate as and when required with relevant

team members to achieve continuity of care.

Sr.No Objective Elements CHNC Remark(s)

a. There is a handover mechanism Yes, Compliant
among the care team across
shifts regarding patient‟s status.
b. Nursing professionals Yes, Compliant This includes
communicate with staff in other patient transfers,
departments when required to ensure requisitioning bedside
that care plan is implemented. services etc. done
through transfer check
list

c. HCO uses predetermined formats Yes, Compliant

for such communication wherever
required.

Standard

ECG.4. Patient and family are educated where essential and in case of any change
in nursing care plan.

Sr.No Objective Elements CHNC Remark(s)

a. Patient and family education Yes, Compliant
includes aspects of care plan.

b. The education shall cover the Yes, Compliant. patient

education booklets
medical condition, pre and post-
operative education, special
procedures, preventing healthcare
associated infections, when to seek
urgent medical attention and home
care wherever applicable.
c. Nursing professionals explain to Yes, Compliant
patient/ family before any procedures
are performed on patients.

d. Nursing professionals ensure Yes, Consent form .

written informed consent exists for all invasive
wherever essential. procedures.

e. Patient and/or family are Yes, Compliant

educated in a language and
format that they can understand.
CHAPTER: 5

INFECTION CONTROL PRACTICES

ICP.1. Infection control nurse (s)shall be designated by the organization
ICP.2. Nursing professionals shall adhere to standard precautions and hand
hygiene guidelines at all times.
ICP.3. The nursing professionals shall adhere to handling, storage and disposal of
bio medical waste as per the bio medical waste management Act, 1998.
ICP.4. The designated nursing staff shall perform surveillance activities to capture
and monitor infection control and prevention data.
ICP.5. Isolation (barrier and reverse barrier nursing) practices shall be supervised
by senior nursing professionals.
ICP.6. Infection Control Nurse maintains records of all occupational injuries and
Standard

ICP.1. Infection control nurse (s) shall be designated by the organization

Sr.No Objective Elements CHNC Remark(s)

a. The criteria for designating ICN Yes, Compliant
shall be based on qualification or
training.

b. Infection control nurse (s) shall Yes, Compliant.

Certificate enclosed
have specialized training (internal
or external) in hospital infection
control.
c. Infection control nurse (s) shall Yes, Compliant
have documented role and
responsibilities.
Standard

ICP.2. Nursing professionals shall adhere to standard precautions and hand

hygiene guidelines at all times.
Sr.No Objective Elements CHNC Remark(s)
a. Nursing professionals are trained Yes, Compliant The The
organization organization
in standard precautions and hand
displays the
adheres to international
hygiene guidelines. necessary
national guidelines on hand instructions
near every hand
hygiene.
washing area.

b. Nursing professionals shall be

Yes, Compliant.
conversant with Personal protective
equipment (PPE) and their use.

c. The organization audits Yes, Compliant. A small study

compliance to standard was Conducted. Attached as
precautions and hand hygiene per appendix
practices.

d. The nursing staff adheres to Yes, Compliant

cleaning, disinfection and
sterilization practices.
e. The nursing staff adheres to safe Yes, Compliant
linen management practices.

f. The nursing staff adheres to the Yes, Compliant

safe injection practices.
g. The senior nursing professionals Yes, Compliant
along with other professionals
identified by the HCO monitor
safe linen management practices
Standard

ICP.3. The nursing professionals shall adhere to handling, storage and disposal of
bio medical waste as per the bio medical waste management Act, 1998.

Sr.No Objective Elements CHNC Remark(s)

a. The organization ensures Yes, Compliant
provision for appropriate biomedical
waste management practices.

b. Where applicable municipal Yes, Compliant .

waste (General waste) rules shall be
complied with by the nursing
personnel.
c. Nursing professionals shall be Yes, Compliant
conversant with disposal of Personal
protective equipment (PPE).
Standard

ICP.4. The designated nursing staff shall perform surveillance activities to capture
and monitor infection control and prevention data.
Sr.No Objective Elements CHNC Remark(s)
a. Surveillance activities are Yes, Compliant
appropriately directed towards the
identified high-risk areas and
procedures.
b. Appropriate feedback regarding Yes, Compliant
HAI rates are provided on a
regular basis to appropriate personnel.

c. The surveillance activities include Yes, Compliant .Culture

swab from ICU, HDU
monitoring of environment and
are taken for
infection control indicators. surveillance.
d. The surveillance activities include Yes, Compliant
monitoring of cleaning, sterilization
and disinfection in patient care units.

Standard

ICP.5. Isolation (barrier and reverse barrier nursing) practices shall be supervised
by senior nursing professionals.

Sr.No Objective Elements CHNC Remark(s)

a. The organization provides Yes, Compliant
appropriate resources for isolation
practices.

b The Nursing professionals are Yes, Compliant

familiar with the type of isolation
(barrier and reverse barrier) facilities
provided by the HCO.
c Senior Nursing Professionals Yes, Compliant .
monitor the nursing activities
provided in isolation facilities.

Standard

ICP.6. Infection Control Nurse maintains records of all occupational injuries and
pre- and post-exposure prophylaxis.
Sr.No Objective Elements CHNC Remark(s)
 a. Hazardous materials specific to
the settings and locations that they Yes, Compliant
work in are identified by the nursing
professionals. (as applicable).

b. The nursing professionals Yes, Compliant .

implement processes for sorting,
labeling, handling, storage,
transporting and disposal of hazardous
materials.
c. The Nursing professionals are Yes, Compliant
aware of the HCOs plan for

managing the spills of hazardous

materials and are able to supervise
and adequately implement the same in
their specific locations of work.

d. Appropriate pre- and post- Yes, Compliant

exposure prophylaxis is provided to
all staff members concern
ed.
 CHAPTER: 6

EMPOWERMENT AND GOVERNANCE

Summary of Standards

EG.1. The responsibilities of those responsible for nursing management are

defined.
EG.2. The Head of the Nursing service ensures that suitable mechanisms exist to
govern the nursing Service.
EG.3. Nursing professionals are involved and participate in decision making related
to organization and nursing services.
EG.4. The Management empowers nursing staff
EG.5. The organization has an established process for proactive risk assessment
and error management.
EG.6. The infection control programme is supported by the management and
includes training of staff.
Standard

EG.1. The responsibilities of those responsible for nursing management are

defined.

Sr.No Objective Elements CHNC Remark(s)

a. Those responsible for nursing Yes,
management lay down the Compliant .Attached as
nursing department vision. per appendix

b. Those responsible for nursing Yes, Compliant

management lay down the
nursing department mission.
c. Those responsible for nursing Yes, Compliant
management lay down the
nursing department values.
d. Those responsible for nursing Yes, Compliant
management establish the
nursing department organogram.

Standard

EG.2. The Head of the Nursing service ensures that suitable mechanisms exist to
govern the nursing Service.
Sr.No Objective Elements CHNC Remark(s)
a. There is an established head of Yes, Compliant. The
head of the
the nursing services.
nursing services is
selected based
upon identified
criteria like
qualifications,
experience and
training received.

b. The scope of Nursing services is Yes, Compliant .

defined in the nursing manual.
c. The Nursing administrative policy Yes, Compliant. .
and procedure is defined in the
manual and implemented.
d. The department manual shall Yes, Compliant .
govern the nursing functions and
activities within the department.
e. Nursing administrative policy and Yes, Compliant
procedure is defined and
implemented.
f. Structured program exists for Yes, Compliant
enhancing clinical competency and
leadership skills of nursing
professionals.
g. The Nursing leaders are involved Yes, Compliant.CNE
was conducted in this
in quality improvement projects
regard.
and program.
Standard

EG.3. Nursing professionals are involved and participate in decision making related
to organization and nursing services.

Sr.No Objective Elements Remark(s)

a. A Nursing Management Yes, Compliant .
committee is established and it meets
periodically to oversee Nursing related
issues.
b. Nursing professionals have
Yes, Compliant
membership in various
committees as appropriate.

c. Nursing professionals providing Yes, Compliant

direct care are involved in action plan
development and evaluation is based
on evidence based data.
d. The organization has a Yes, Compliant
mechanism to seek feedback .
from nursing professionals and
other staff regarding the quality of
nursing care and to for evaluating
nursing satisfaction.

Standard

EG.4. The Management empowers nursing staff.

 Sr.No Objective Elements CHNC Remark(s)
a. There is a policy on nursing Yes, Compliant
.
empowerment to ensure timely
nursing care of patients.
b. Management empowers nursing Yes, Compliant
staff by involving them in decision
making.
c. Management empowers nursing Yes, Compliant
staff by appraisal and Job incentives,
encouraging innovation.

d. Management empowers nursing

Yes, Compliant
staff by supporting education.

e. Management empowers nursing .

Yes, Compliant
staff by promoting interpersonal
relationships.

Standard
EG.5. The organization has an established process for proactive risk assessment

and error management.

Sr.No Objective Elements CHNC Remark(s)

a. The Nursing service has clearly Yes, Compliant
defined error prevention, error reporting and
error addressing mechanisms and the same are
documented.
b. The Nursing professionals are Yes, Compliant
provided with adequate resources including
materials and equipment for providing safe and
efficient nursing services.

c. The nursing structure and Yes, Compliant

processes support a culture of patient
safety.
d. The Nursing professionals are Yes, Compliant
made aware of and are trained in code blue
drills, disaster management and emergency
situations inclu ding fire and non fire
emergencies.

e. The standards of personal health Yes, Compliant

and safety of the nursing professionals are
maintained such that ability to practice is not
compromised.
f. There is an escalation process for Yes, Compliant .
nursing professionals when emergency
and life threatening
situations arise
Standard

EG.6. The infection control programme is supported by the management and

includes training of staff.
Sr.No Objective Elements CHNC Remark(s)
a. The management makes Yes, Compliant
available resources required for the
infection control practices.
b. The organization conducts Yes, Compliant
induction training for all staff.

c. The organization conducts Yes, Compliant. Documents .

attached
appropriate “in-service” training
sessions for all staff at least once in a
year.
 CHAPTER: 7

NURSING QUALITY INDICATORS

Summary of Standard

NQI.1. There is a structured quality improvement and continuous monitorin

program for nursing service.
NQI.2. The organization identifies key indicators to monitor the structures,
processes and outcomes, which are used as tools for continual improvemen
for nursing service.
NQI.3. The nursing quality improvement programme is supported by th
management.
Standards and Objective Elements

Standard

NQI.1. There is a structured quality improvement and continuous monitoring

program for nursing service.

Sr.No Objective Elements CHNC Remark(s)

a. The quality improvement Yes, Compliant by
following the SOPs
programme is developed, implemented
and maintained by a committee with a
representative from nursing personnel.

b. There is a designated individual Yes, Compliant

for coordinating and implementing the
nursing quality-improvement
programme.
c. The quality improvement Yes, Compliant .
programme shall be reviewed at
periodic intervals.
Standard

NQI.2. The organization identifies key indicators to monitor the structures,

processes and outcomes, which are used as tools for continual improvement
for nursing service.

Sr.No Objective Elements CHNC Remark(s)

a. The patient falls are monitored Yes, Compliant.
Incident reporting is
and the incident of patient falls is
done
documented by the appropriate nursing
professionals.
b. The hospital acquired decubitus / Yes, Compliant
pressure ulcers in various departments
are monitored and recorded as per laid
down protocols by the HCO.

c. The medication errors during Yes, Compliant

provisioning of care are monitored and
recorded on occurrence by the
concerned nursing staff in forms as
laid down by the HCO.
d. Monitoring of accidental delining Yes, Compliant
(if applicable).
e. All extravasations are recorded Yes, Compliant .
and monitored as per the laid
down protocols.
f. All needle stick injuries are Yes, Compliant .
documented and monitored as per
the policy laid down by the HCO that
should be in consonance with the
national and International guidelines.

g. All restraint related incidents Yes, Compliant

including strangulation are
monitored and documented.
Sr.No Objective Elements CHNC Remark(s)
 h. The hand hygiene compliance is Yes, Compliant .
monitored and recorded by the nursing
professionals responsible for the same.

i. The compliance with pain Yes Compliant as per

the I/O chart.
assessment and management is
monitored by the senior nursing
professional while undertaking their
professional rounds and the same is
documented.
j. The satisfaction of patients with Yes Complaint. Patient .
feedback book.
the nursing care is monitored by the
senior nursing professionals and the
same is documented.

Standard

NQI.3. The nursing quality improvement programme is supported by the

management.
Sr.No Objective Elements CHNC Remark(s)
a. The management makes Yes Complaint. we
have. adequate
available adequate resources required
resources
for quality improvement programme.

b. The management supports and Yes, Compliant

implements use of appropriate quality
improvement, statistical and
management tools in its quality
improvement programme.
c. The senior nursing professionals Yes, Compliant
.
as delineated by the HCO also monitor
the nursing satisfaction based on pre
determined criteria in consultation
with the Human resource department
of the HCO.
d. The attrition rate and frequency of Yes, Compliant
attrition of the nursing professionals is
monitored and documented by the
head of the nursing in consultation
with the human resource department
of the HCO.
Standard

NQI.4. There is an established system for nursing audit.

Sr.No Objective Elements CHNC Remark(s)

a. Nursing staff participates in Yes, Compliant
the audit.

b. The parameters to be audited Yes, Compliant

are defined by the
organization.
c. Patient and staff anonymity is Yes, Compliant
maintained.

d. All audits are recorded and Yes, Compliant

reviewed.

e. Implementation is recorded Yes, Compliant

and reviewed.
Standard

.5. Incidents, complaints and feedback from nursing professionals are collected
and analysed to ensure continual quality improvement.

Sr.No Objective Elements CHNC Remark(s)

a. The organization has an incident Yes, Compliant There is
a incident
reporting system.
reporting system
.
b. The organization has a process to Yes, Compliant. It is This shall be
communicated to the
collect feedback and receive .
patients using displays
complaints. or brochures

c. The organization has established Yes, Compliant

processes for analysis of

incidents, feedbacks and
complaints.

d. Corrective and preventive actions Yes, Compliant

are taken based on the findings of such
analysis.

e. Feedback about care and service Yes, Compliant

is communicated to staff.