Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 4 Nursing Services

TOPIC 4.1: ORGANISATION AND MANAGEMENT

STANDARD 4.1.1

The Nursing Services shall offer high standard of care to the community, as inpatients and outpatients in a
safe, effective, efficient and caring manner; and shall be organised, directed and coordinated with the other
services in the Facility.

CRITERIA FOR COMPLIANCE:

4.1.1.1 There are documented purposes which may be termed Vision and Mission statements, goals,
objectives and values that suit the scope of the Nursing Services. When compiling the purposes,
consideration shall be given to the following:

a) They are what the services want to achieve.

b) The goals of the service are achieved by the objectives as stated.

c) The goals and objectives are consistent with professional standards, guidelines and
relevant legislation.

d) Statements are monitored, reviewed and revised as required accordingly.

4.1.1.2 There is an organisation chart which:

a) provides a clear representation of the structure, function and reporting relationships

between the Head and the staff of the Nursing Services;

b) is accessible to all staff;

c) is revised when there is a major change in any one of the following:

 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.

4.1.1.3 There is an organisation chart at each service level which reflects the working relationships
between the Person In Charge (PIC), medical practitioners and nurses.

4.1.1.4 There are written and dated specific job descriptions for all nursing staff that include:

a) qualifications, training, experience and certification required for the position;

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b) lines of authority;

c) accountability, functions and responsibilities;

d) review when required and when there is a major change in any one of the following:

 nature and scope of work;

 duties and responsibilities;
 general and specific accountabilities;
 qualifications required and privileges granted;
 staffing patterns;
 Statutory Regulations.

4.1.1.5 Regular staff meetings are held to discuss issues and matters pertaining to the operations of the
Nursing Services. Minutes are kept and are accessible to all nursing staff.

4.1.1.6 Personnel records on training, staff development, leave and others are maintained for every staff.

4.1.1.7 The Head of Nursing Services is involved in the planning, management and justification of the
budget and resource utilisation of the services.

4.1.1.8 The Head of Nursing Services is involved in the appointment and/OR assignment of staff.

4.1.1.9 The Head of the Nursing Services shall ensure that the staff of Nursing Services complete
incident reports which are discussed by the services with learning objectives and forwarded to the
Person In Charge (PIC) of the Facility.

4.1.1.10 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.

4.1.1.11 Appropriate statistics and records shall be maintained in relation to the provision of Nursing
Services and used for managing the services and patient care purposes.

4.1.1.12 The planning, implementing and evaluation of the Nursing Services are guided by documented
nursing philosophy, goals and objectives.

4.1.1.13 There is evidence that nursing philosophies, goals and objectives are utilised and reviewed
regularly and when necessary.

4.1.1.14 There is evidence that the Nursing Services are involved in the development and implementation
of new technologies.

4.1.1.15 The Head of Nursing Services participates in the planning, development and evaluation of
nursing facilities and services.

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4.1.1.16 Where the Facility provides clinical experience for students of nursing, there is a comprehensive
documented agreement between the Facility and the educational institution detailing the
responsibilities of all parties, which shall include:

a) time period;

b) liability;

c) review of terms of contract;

d) accountability for clinical nursing practice.

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TOPIC 4.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD 4.2.1

The Nursing Services shall be directed by a suitably qualified and experienced registered nurse, and
adequately staffed to achieve the goals and objectives of the Nursing Services.

CRITERIA FOR COMPLIANCE:

4.2.1.1 The direction by the Head and staffing of the Nursing Services are provided by individuals
qualified by education, training, experience and certification to commensurate with the demands
of the various positions.

4.2.1.2 The Head of Nursing, however named is a member of the Senior Management Team and sits on
relevant committees of the Governing Body.

4.2.1.3 A suitable qualified registered nurse has delegated responsibility for the management of the
Nursing Services at all times.

4.2.1.4 Each nurse is currently licensed to practise nursing and is professionally qualified for the position
held.

4.2.1.5 The assessment, planning, implementation and evaluation of nursing care are the responsibility
and accountability of registered nurses.

4.2.1.6 Nursing staffing patterns shall reflect:

a) patient needs / patient acuity level;

b) staffing profile (numbers, qualifications, and experience of the various categories of

nursing staff) to comply with relevant guidelines and regulatory requirements;

c) contingency staffing plan (absenteeism, turnover etc.).

4.2.1.7 There is a structured orientation programme where new nursing staff are briefed on their services,
operational policies and relevant aspects of the Facility to prepare them for their roles and
responsibilities.

4.2.1.8 The orientation programme for all newly appointed staff to the Nursing Services and for those
new to specific areas shall include the following:

a) explanation of the philosophy, goals, objectives, policies and procedures of the Facility
and those of the Nursing Services;

b) lines of authority and areas of responsibility;

c) explanation of particular duties and functions;

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d) explanation of the methods of assigning nursing care, and the standards of nursing
practice;

e) processes for resolving practice dilemmas;

f) information about safety procedures;

g) training in basic life support techniques;

h) methods of obtaining appropriate resource materials;

i) staff appraisal procedures for the Nursing Services;

j) education on Patient and Family Rights.

4.2.1.9 Staff receive written evaluation of their performance at the completion of the probationary period
and annually.The staff appraisal system shall include the following:

a) identification of strengths in performance and areas for improvement;

b) accomplishment of objectives;

c) compliance with job description;

d) compliance with professional standards and guidelines for practice;

e) evidence that staff are involved in the appraisal of their performance;

f) the completed performance appraisal is signed, reviewed, and acted upon;

g) appraisal shall be done by relevant nursing personnel with input from medical practitioners.

4.2.1.10 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of the positions evolve.

4.2.1.11 There is continuing nursing education programme for staff to pursue professional interest and to
prepare for current and future changes in practice. There is evidence that staff education and
development needs have been appraised and identified.

4.2.1.12 In a Facility where nursing education programmes are conducted, the Nursing Services ensure
that there are sufficient skilled clinical nurse teachers with appropriate experience to provide
clinical guidance and supervision of students.

4.2.1.13 The nursing staff participating in the teaching/training/patient care of students in the Facility are
credentialed and privileged.

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4.2.1.14 The Nursing Services shall ensure the establishment of a mechanism which includes
requirements, methodology and certification for credentialing and delineation of privileges for
nurses in specialised areas for specific procedures. The mechanism taken by the Nursing
Services adhered to the following:

a) the written policies and procedures documents the criteria for privileging;

b) the decisions made are objective, fair, and impartial;

c) the granting of privileges for a specified period of time;

d) the allocation of privileges in such a way that each staff functions within a specified area of
competence;

e) the granting of privileges is approved by the Hospital Credentialing and Privileging

Committee and certified by the Person In Charge (PIC)/Governing Body.

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TOPIC 4.3: POLICIES AND PROCEDURES

STANDARD 4.3.1

There are written and dated policies and procedures for all activities of the Nursing Services. These policies
and procedures reflect current standards of nursing services and practice, relevant regulations, statutory
requirements, and the purposes of the services.

CRITERIA FOR COMPLIANCE:

4.3.1.1 There are written policies and procedures for the Nursing Services and they are consistent with
the overall policies of the Facility which include:

a) policies and procedures, applicable laws and regulations that guide uniform nursing care of
all patients;

b) policies and procedures that guide the care of high risk patients and high risk services;
emergency patients, use of resuscitation services, administration of blood and blood
products, patients on life support/comatose, patients with communicable disease, immuno-
compromised patients, patients on dialysis, care of patients on restraints, care of elderly
patients, disabled individuals and children, and patients receiving chemotherapy and other
high risk medications;

c) policies and procedures on patient nutrition and sanitation.

4.3.1.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.

4.3.1.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.

4.3.1.4 New and revised policies and procedures are communicated to all staff.

4.3.1.5 There is evidence of compliance with nursing and related policies and procedures.

4.3.1.6 Copies of policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.

4.3.1.7 The Head of Nursing Services is responsible for the organisation, documentation and
implementation of nursing policies and procedures.

4.3.1.8 The Nursing Services participate in planning, decision making and formulation of polices of the
Facility.

4.3.1.9 The Nursing Services have an established initial assessment process for patients where their
nursing needs are identified and followed by regular reassessment as deemed as necessary.
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4.3.1.10 Nursing practice is in accordance with nationally accepted standards based on current evidences
and shall include the implementation of the nursing care plan:

a) documented individualised patient-focused nursing care plan for each patient to achieve
appropriate outcomes;

b) monitoring of the patient to assess the outcome of the care of patient;

c) reviewing and modifying the care plan where appropriate;

d) completing the care plan with proper documentation;

e) planning and follow up, to include discharge planning that reflects continuity of care;

f) patient education which shall be documented.

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TOPIC 4.4: FACILITIES AND EQUIPMENT

STANDARD 4.4.1

There are adequate and appropriate facilities and equipment at each nursing unit for providing safe and
efficient nursing services.

CRITERIA FOR COMPLIANCE:

4.4.1.1 There is adequate and proper utilisation of space and storage to allow staff to carry out their
duties safely and efficiently according to standards set by the relevant authorities and regulatory
requirements.

4.4.1.2 Nursing services are provided with sufficient supplies and equipment at all times.

4.4.1.3 Equipment is operated by suitably trained and qualified personnel.

4.4.1.4 There is sufficient personal protective equipment available.

4.4.1.5 There are sufficient change rooms, rest areas for staff use and storage including safekeeping of
their requisite personal items.

4.4.1.6 Facilities which provide nursing training shall have specific areas for training and rooms for
tutorial.

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TOPIC 4.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

STANDARD 4.5.1

The Head of Nursing Services shall ensure the provision of quality performance and safety of patients with
staff involvement in the continuous safety and quality improvement activities of the Services.

CRITERIA FOR COMPLIANCE:

4.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement activities
within the services.

4.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.

4.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:

a) percentage of intravenous (I/V) line complications (needles out, redness of skin, infection
of sites, extravasation)

b) percentage of Nursing Care Plan completed on discharge

c) average time the discharge order is written until the patient actually leaves the ward

Notes/Explanations

Reports are available on indicators include tracking and trending for specific performance
indicators carried out.

4.5.1.4 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.

4.5.1.5 Appropriate documentation of safety and quality improvement activities is kept and confidentiality
of staff and patients is preserved.

4.5.1.6 There are safety and quality improvement activities that address staff safety.

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