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    Nursing Staff Development Dr. PJGMRMC

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    HOSPITAL NURSING SERVICE ADMINISTRATION MANUAL (> DEPARTMENT OF HEALTH o Health Facility Development Bureau (HFDB) ere” | HosPITAL NURSING SERVICE ADMINISTRATION MANUAL Published by the Department of Health (DOH) Health Facility Development Bureau (HFDB) Copyright @ 2019 All right reserved, No part of this book may be reproduced or used in any form or by any means, electronic or mechanical, including photocopying, recording, scanning or by any information storage and retrieval system without permission in writing from the publisher. Repub ofthe Pipi Department af Health OFFICE OF THE SECRETARY AUTHORIZATION December 16, 2019 Inaecordance with the authority vested on the Seretary af Health, thereby declare the policies, regulations, and instructions inthis Manual for Nurses shall govern the organization, ‘management, and activities ofthe Nursing Service in govemmment hospitals uni] madified by ‘order of the Department of Health or by law. pl? Foo hae Secretary of Health Dee FN Fae SN 9 URL ene agen Republi ofthe Pires Department of Health OFFICE OF THE SECRETARY MESSAGE Moving towards the realization ofits vision of hailing Fipinos among Southeast Asia's hesthiest people in 2022 and in Asia by 2040, the Department of Heath (DOH) urges the health sector towards cevelopment of a Productive, Resiion! Equitable, end Poople-centered health sector, as outined in the Stetegy Mep of the DOH's FOURmula One Plus (Ft Plus) for Health. ‘Aiming for better health outcomes, more responsive health system, and more {equitable healthcare financing, especially now that the mandate fo: the implementation ‘ofthe Universal Health Care Act has been geared at full capacity, measures fo ensure high-quality and affordable health products, devices, facities and services are essential ‘with these in mind, | commend the Health Faclity Development Bureau (HFDB), for their initiative and! commitment to harmonizing and stroamilining standards and ‘processes in health facility operations throuch its undertaking to update the Manual of Standards for Hospital Nursing Service Administration. Emulating the Departments Core values of integrity, excellence and compassion, indeed, the Nursing Service Is a fundamental aspect of hospital operations, wherein the nurses act as agents and ambassadors forthe health sector In is entirety Hence, we tust that the undated standards defined in this manual shall serve 2s & Felevant basis lo benchmark enrichment of equitable access to quality heath facities that offer heallh services compliant to the slandards of care. Keeping ie mind Performance accountabilty across alt pilars of F1 Plus, particularly service delivery, may these manual, along with the HFOB's engagemen to is partners inthe delivery ‘f quality heath care fo all, ease the beter execution of policies and programe in tre DOH, ‘Aligned with the mandete of UHC towards a people-centered approach for delivery of health services that is focused on people's neecss and well-being, while recognizing the Filipino people's varying cullures, belle, and values, we are confident that this. ‘manual shell be instrumental in fuffiling the DOH's aspiralon of delivering *Kalusugang Pangkalahatan" tra tis nation needs ii hh oc 1 06 teas ol hn pp kephke ot ths Pacipeoe Depistiment.e? Heath OFFICE OF THE SECRETARY WESSAGE ‘#fin the implementa’ on of ihe Universal Heeltt Care (UHC} Law, Figinos wi have better health outcomes across papualion groups a more resporwive hesith system Wa races people feel resnected, valued and ovizowered, and financial risk crotecsion Health faciites are shee paliasts expect lo excesience the best Health care and taatire Heallr feciiies must ier be venues of cle.co qLabty, oporallanal nffleloncy anc people. centeree processes. ‘Tine upcia'ed Hospital Nursing Servico Administration Manual aims to bettor respene to ppatiant noods ay wwctng the Ietest develoamnenis in evidence-based nursing care enc aragamart practicas. We have accounted for the diverse spectrum ef heat oars settings and resources, while kancing Inip to the fundamental princinle cf etfert anc etfective elivery of 9 con:raum of gcalty care, Tris msruat is organized i1 two carts, Past 1's on Acimin’stralion of Nursing Services, which Siscusses the Tends and directions for the DO and the nursing service, as well as ‘Techenisms to Improve planning. organization, stating. diroclng and controlling of the qursing service. Part lis 0 Mansy tier Lol Heallhcare Delivery, which dscusses fie bends fon nyrshg processes, viodattlas of care, quilly maraagerrer’, siely, rive manager! vfermatioameragernet eystem. athica-tuga arses, human ¢asens Hs 9a i ME, AH see EOAL ‘We anjein mary tatty worker frory top manazcmen: 19 fostine avd to Invigarale angagemser chrough con’ reous earring, 9807 cUppon anc ran ieplorant tho stancords ir this Meret as mast approprisce in their respect ‘Thank you vory érucr and 29s! wishes "0 al LS! LILIBETH © DAVID, M0, MPY,MPME ESOT Ledersecretary of Heath Health Facilities ma! Infrastructure Doveloganeat Yess Su’: 2, Sur steamed 7a are, St tne, EE MAP 9H. Ak Une BAPE 11S, ‘Ck HLTEDE TA1G003 Fan TAURINE NAIK A REV MAL) nO epublio cats Poppies Dypicment of Hens ADMINISTRATION AND FINANCIAL MANAGEMENT TEAM MESSAGE, The government through the Department of Health is committed town making Filipinos the ‘eatbesin Southeast sia by 2022, and in Asia by 2040, Lo soalto ths vision, iLis importa {hat we hess a heath stem thee aot eal superior in kerma of providing topnotch fclliis, evioss and services hut is aso responsive and sensitive t elem’ pigs and noes, With the Lieiversa! Rewth Cane Sally cai ofl ti naw only a marr of time for wo see that apart fam snaking veacennbly pried halts services uni cursmaxitiss accessible 2nd ‘enable tothe padli, heallh faites aso give equal prem bo naming wo ezrin ots inurl ent patients Go this note, | cougratulie the Holl Peellty Development ureay fr this another unilesione. ‘We arc coufident thar this upate eden of Hospital Nurs Service Adbinisretion Mencal will hefp rise the quality of nursing care snd services that nase pris lo tei pation ‘whether they ons woking in pulvat Ge sacs rur hospitals and miecical genera, hehe 5 os a as vce MTS mA, MAN, trier nal dec Nangene Ta FOREWORD evelopment Bureau (HEDB) of the Department of Health is charged vist leading in dhe continuots developanems of quality health foellices shat are efficient and eespousiy we Filipivus. Taveates this end, the Burcew ie eréearted to develop policies, programs and standards, as well as provide technical assistance and advisory services in the development, planning, operations and maintenance of health facilities For he BOY'S Payship pragram to 390et Universat Heal Cars, FGURmad: One Plus for Meath, the HEDB is commitied tw the Gevelopment of the Philippine Health Fecilis Development Plan, policies and recognition mechanisms on People-Centered Health Care Services, Patient Sa:ety and Infection Prevension and Control, and manuals on health Tacility operations for quality services and integration. All these strategic functions serve to jplement the DOH's mandates in the implementation of Republic Act No. 11223, of the Universal Health Care Act. ‘The targeted health facility manuals include this updated edition of the Hospital Nursing Service Administration Manual. The HFDB is extremely grateful for the generosity of the “Fechaizat Working Group intanders, the invited resource pers her stakeholler, whe Ceaizated their tiers, expertise and eff to enstie thal ths I-est edition of the ssamal sluill be of sufficient content and convenient form to address the haesitals’ necels fer continuous quality improvement especially among nursing service administrators andl staf Tx teat Aaciliyy is dhe people's primary interface with the health system, I is at this juneture, where the Filipinos’ expeetations and the genuine ehanges brought by Universal Health Care intersect. The Bureau hopes that this and our other initiatives, as well as your sills he DOH'S goals of financis! risk ¢ responsive health service delivery er health outcomes Fo all protection, a mo ep ih deabsnten /.WERA. MD, Me, MHS, CESO MIT Director 1V Heaith Facility Development Buzeats PREFACE It is indeed with profound appreciation and gratitude that I acknowledge the members of the Technical Working Group (TWG) and Technical Contributors, who collectively shared their knowledge and competence in the preparation of this 4 Edition of the Hospital Nursing Service Administration Manual. Today’s health care organizations face tremendous challenges. In any given day of running organizations, these challenges become pressures that impact the decisions that managers make and execute. This Manual intends to explain how organizational goals can be achieved, and it shall define the scope of activities to be conducted to accomplish such goals. This Manual was designed to ensure accessibility and flexibility of more efficient operations of nursing activities with tools provided to meet needs in the development, promotion and enhancement of quality nursing care. ‘The Department of Health (DOH), in consultation with stakeholders, reviewed and updated the Manual mindful to make introduction and application of new knowledge more practical ‘The reviews entailed all the chapters published from the third edition, and new chapters were added to address the clinical practices of nurses in DOH Hospitals. The text expanded to ensure more practical advice speaks to the needs of administrators to respond more effectively to problems and issues in aid of management. For this 4"" Edition, the Manual’s chapters are reorganized and regrouped according to similar aspects of management and nursing care. Part I covers the Administration of Nursing, Services in which information and discussion on major functions of Nursing Administrators are aimed to inspire desirable attitudes and predisposition to perform duties and responsibilities such as setting appropriate courses of action according to necds that arise. Part II addresses the Management in the Delivery of Nursing Care Services in which competencies that are essential for the development of the nursing staff are identified, the competencies that enable performance of roles and responsibilities in promotive, preventive, curative and rehabilitative aspects towards attainment of quality patient care. ‘This Manual is eapped with appendices of step-by-step processes and procedures, as well as a list of references or sources from which many updated information herein were drawn. On behalf of TWG and the Technical Contributors, we at the Health Facility Development Bureau (HFDB) of the DOH wish that your continual use of this Manual will significantly contribute to the optimal development of Nursing Service Administration, truly responsive and effective in the management of nursing care services in the hospitals. 7, ‘an le a ZENAIDA ILA VILLALUNA, RN, MAN, Ed.D. Development Management Officer IV (DMO IV] Nursing Advser Chairperson, Committee on Revision DOH Hospital Nursing Service Administration Manual ACKNOWLEDGEMENT ‘The Department of Health, Health Facility Development Bureau (HFDB), would like to express deepest gratitude with the participation of several DOH Hospitals and previous committee in the revision of 2008 Hospital Nursing Service Administration Manual, for their invaluable contribution, support and encouragement made this 2019 Revised Manual a reality. Dr. Lilibeth C. David, Undersecretary of Health, Health Facilities and Infrastructure Development Team; Dr. Gerardo V. Bayugo, Undersecretary of Health, Field Implementation and Coordination Team; Dr. Roger P. Tong-an, Undersecretary of Health, Administration and Financial Management; Dr. CriseldaG. Abesamis, former Director IV, DOH, Health Facility Development Bureau (HFDB) Dr. Ma. Theresa G. Vera Director IV, DOH, Health Facility Development Bureau To all DOH Medical Center Chiefs, Chief of Hospitals and staff for allowing their Chief Nurses to attend series of Consultative Conferences in the revision of the said Manual. Our deepest thanks and appreciation to the following Medical Center Chiefs for their invaluable support and for offering their resources during committee meetings: Dr. Alfonso G, Nufiez, East Avenue Medical Center; Dr. Epifania Simbul, National Children’s Hospital; Dr. Jose Brittanio S. Pujalte, Philippine Orthopedic Center; Dr. Evelyn Victoria E. Reside, Quirino Memorial Medical Center; Dr. Maria Isabelita M. Estrella, Tondo Medical Center; Dr. Jeffrey Antony T. Canceran, Batanes General Hospital; Dr. Ramoncito C. Magnaye, Batangas Medical Center; Dr. Alfonso Victorino H. Famaran, Dr. Jose N. Rodriguez. Memorial Hospital; Dr. Agustin D. Agos, Talisay District Hospital; Dr. Gerardo M. Aquino Jr., Vicente Sotto Memorial Medical Center; Dr. Bryan O. Dalid, Davao Regional Medical Center; Dr. Leopoldo J. Vega, Southern Philippines Medical Center; Likewise, we would wish to express our thanks to the Technical Working Group (WG), Contributors and Nursing Consultants, who patiently reviewed and took necessary changes to make this new edition relevant to the needs of today’s Nursing Service Administration: Technical Working Group (TWG) on the Committee on the Revision of the Hospital Nursing Service Administration composed of: Chairperson, Dr. Zenaida I. Villaluna, HFDB, DMO IV, (Nursing Adviser); Members, Ms. Daisy L. Llarenas, Chief Nurse, National Children’s Hospital; Dr. Evelyn T, Monsanto, former Chief Nurse, Zamboanga City Medical Center; Dr. Amor B. Calayan, Chief Nurse, Batangas Medical Center; Ms. Flordeliza R. Bobiles, Chief Nurse, locos Training and Regional Medical Center; Dr. Vilma L, Comoda, Chief Nurse, Southern Philippines Medical Center; Dr. Laura B. Libunao, Chief Nurse, Philippine Orthopedic Center; Mr. Joselito M. Datud, Chief Nurse, Baguio General Hospital and Medical Center, Ms. Marybeth G. Marcial, Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital Contributors, Dr. Nora B. Mangahas, Chief Nurse, Amang Rodriguez Memorial Medical Center; Dr. Flor P. Burgos, Chief Nurse, East Avenue Medical Center; Ms. Ma. Mercy C. Coral. Chief Nurse, Davao Regional Medical Center; Ms. Pinky Miriam D. Canlas, Chief Nurse, Dr. Paulino J. Garcia Memorial Research and Medical Center, Ms. Edna E. Solis, Chief Nurse, Dr. Jose Fabella Memorial Hospital; Ms, Rhodora D. Quilantip, Chief Nurse, Tondo Medical Center; Ms. Miriam I. Ramones, Chief Nurse, Mariano Marcos Memorial Hospital and Medical Center; Dr. Luz P. Padua, Chief Nurse, Quirino Memorial Medical Center; Ms. Marieta I, Gonzales, Chief Nurse, Region 1 Medical Center; Ms, Alicia N. Salamanca, Chief Nurse, Jose R. Reyes Memorial Medical Center; Ms. Sheila M. Mira, Assistant Chief Nurse, Norther Mindanao Medical Center, Ms. Elvira N. Baura, Deputy Executive Director I, Lung Center of the Philippines; Ms, Elsie Sarabia, former Chief Nurse, Jose R. Reyes Memorial Medical Center; Nursing Consultants, Dr. Lucila . Espinosa, former Chief Nurse, National Center for Mental Health; Dr. Marie Therese Pacabis, former Chief Nurse, Dr. Jose Fabella Memorial Hospital; Dr. Leonora Collantes, former Chief Nurse, St. Luke’s Medical Center; Dr. Elvira Urgel, Dean, Centro Escolar University School of Nursing; Dr. Erlinda C. Palaganas, Philippine Nurses Association; Ms. Charity Y. Perea, National League of Philippi Inc.; Dr. Glenda $. Arquiza, Chairperson, Professional Regulatory Board of Nursing; Dr. Gloria B. Arcos, Member, Professional Regulatory Board of Nursing; Ms. Balbina M. Borneo, President, Mother & Child Nurses Association of the Philippines; Dr. Annabelle Borromeo, former Chief Nurse, St. Luke’s Medical Center; Dr. Nancy M, Felipe, Philippine Women’s University Dr. Cristina Caalim, Philippine Society for Quality in Healthcare; Dr. Ma. Linda G. Buhat, President, Association of Nursing Service Administrators of the Philippines; Ms. Tloida M. Flores, Nurse V, Health Facilities and Services Regulatory Bureau; Mr. Manuel Castillo Jr. SR HRS, DOH-Civil Service Commission Government Nurses Secretariat, Ms. Sarah Sacdalan-Levy, HFDB, DMO IL Also, our deepest gratitude to all Chief Nurses and Stakeholders representing DOH Hospitals from NCR, Luzon, Visayas and Mindanao for participating in the review of the manual: Ms. Elvira N. Baura, Deputy Executive Director III, Lung Center of the Philippines; Dr. Nerissa M. Gerial, Deputy Executive Director, National Kidney and Transplant Institute: Dr. Amelinda S, Magno, Deputy Executive Director, Philippine Children’s Medical Center; Ms. Marietta A. Velasco, Acting Deputy Executive Director, Philippine Heart Center, Dr. Nora B. Mangahas, Chief Nurse, Amang Rodriguez Memorial Medical Center; Ms. Edna E. Solis, Chief Nurse, Dr. Jose Fabella Memorial Hospi Dr. Flor P. Burgos, Chief Nurse, East Avenue Medical Center; Ms. Alicia N. Salamanca, Chief Nurse, Jose R. Reyes Memorial Medical Center; Mr. Publio B. Plotefia II], Chief Nurse, National Center for Mental Health; Ms. Daisy L. Llarenas, Chief Nurse, National Children’s Medical Center; Dr. Laura B. Libunao, Chief Nurse, Philippine Orthopedic Center, Dr. Luz P. Padua, Chief Nurse, Quirino Memorial Medical Center; Ms, Loida A. Oliquino, Chief Nurse, Research Institute for Tropical Medicine; Ms. Louise Marie Flores, Chief Nurse, Rizal Medical Center; Ms. Ofelia C. Ibarrientos, Nurse VI, Rizal Medical Center Mr. Ferdinand A. Lazaro, Chief Nurse, San Lazaro Hospital; Ms. Rhodora D, Quilantip, Chief Nurse, Tondo Medical Center; xil Ms. Flordeliza R. Bobiles, Chief Nurse, locos Training Regional & Medical ‘Center; Ms. Miriam 1, Ramones, Chief Nurse, Mariano Marcos Memorial Hospital & Medical Center; Ms. Marieta I. Gonzales, Chief Nurse, Region 1 Medical Center; Mr, Joselito M. Datud, Chief Nurse, Baguio General Hospital & Medical Center; Ms. Norzalyn C. Baguec, Chief Nurse, Conner District Hospital; Ms. Wennie C, Lawat, Nurse Supervisor, Far North Luzon General Hospital & Training Center; Ms. Carmelita O. Lud-ayen, Chief Nurse, Luis Hora Memorial Regional Hospital; Ms, Agnes V. Delfin, Nurse Supervisor, Batanes General Hospital; Ms. Olivia $.B. Gonzales, Chief Nurse, Cagayan Valley Medical Center; Ms. Rosalinda C. Mendoza, Chief Nurse, Southern Isabela General Hospital; Ms. Nelia M. Vicente, Chief Nurse, Veterans Regional Hospital; Ms. Evelyn R. Rubia, Chief Nurse, Bataan General Hospital; Ms. Pinky Miriam D. Canlas, Chief Nurse, Paulino J. Garcia Memorial Research & Medical Center; Ms, Luz M. Chiong, Chief Nurse, Jose B. Lingad Memorial Regional Hospital; Dr. Amor B. Calayan, Chief Nurse, Batangas Medical Center, Ms. Leticia D. Romero, Chief Nurse, Mariveles Mental Hospital; Mr. Ericson L. Co So, Chief Nurse, Talavera Extension Hospital; Dr. Amor B, Calayan, Chief Nurse, Batangas Medical Center; Ms, Lynn A. Sotero, Chief Nurse, Culion Sanitarium and General Hospital: Ms, Maria Theresa P. Silva, Nurse V, Ospital ng Palawan Ms, Amelia V. Enriquez, Chief Nurse, Bicol Medical Center; Ms. Cecilia E. Dela Peita, Chief Nurse, Bicol Regional Training & Teaching Hospital; Ms. Shirley P. Orain, Chief Nurse, Bicol Sanitarium; Mr, Samuel C, Sumilang, Chief Nurse, Dr. Jose N. Rodriguez, Memorial Hospital; Ms. Josephine L. Balubar, Chief Nurse, Las Pifias General Hospital & Satellite Trauma Center; Ms. Leonora B. Destacamento, San Lorenzo Women’s Hospital; Ms. Dona D. Salmos, Chief Nurse, Valenzuela Medical Center; Ms. Marybeth G. Marcial, OIC-Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital; Ms. Ma. Cecilia G. Montero, Chief Nurse, Don Jose Monfort Medical Center Extension Hospital; Ms. Violeta C. Calopez, Chief Nurse, Western Visayas Medical Center; Ms, Ma. Eloisa S, Penado, Chief Nurse, Westem Visayas Sanitarium; Ms. Ma. Corazon OQ. Sarabosing, Chief Nurse, Don Emilio Del Valle Memorial Hospital; Ms. Leny B. Maramara, Chief Nurse, Eversely Child Sanitarium; Ms. Tita S. Araneta, Chief Nurse, Gov. Celestino Gallares Memorial Hospital; Ms. Jonah Lydia G. Langga, Chief Nurse, St. Anthony Mother & Child Hospital; Mr. Harby O. Abellanosa, Chief Nurse, Talisay Distriet Hospital; Ms. Sara V. Sanchez, Chief Nurse, Vicente Sotto Memorial Medical Center; Ms. Fe Cuaton, Chief Nurse, Eastern Visayas Regional Medical Center; Dr. Dolores Y. Casio, Nurse VI, Eastem Visayas Regional Medical Center; Ms. Luisa G. Villocino, Chief Nurse, Schistosomiasis Control & Research Hospital; Ms. Marilyne G. Ibarra, Chief Nurse, Basilan General Hospital; Ms. Adora Tambasen, Chief Nurse, Dr. Jose Rizal Memorial Hospital; Ms. Marylou O. Mercado, Chief Nurse, Labuan Public Hospital; Ms. Nona C. Galvez, Chief Nurse, Margosatubig Regional Hospital; Ms. Josephine C. Paragas, Chief Nurse, Mindanao Central Sanitarium; Ms. Juvelyn T. Tan, Chief Nurse, Sulu Sanitairum; Ms. Ellen V. Macias, Chief Nurse, Zamboanga City Medical Center; Ms, Marilyn D. Lueman, Chief Nurse, Amai Pakpak Medical Center, Ms. Gerlie S. Alima, Chief Nurse, Mayor Hilarion A. Ramiro Sr. Medical Teaching Hospital; Ms. Mary Ann S. Pacana, Chief Nurse, Northern Mindanao Medical Center; Ms. Ma. Mercy C. Coral, Chief Nurse, Davao Regional Medical Center; Dr. Vilma L. Comoda, Chief Nurse, Souther Philippines Medical Center; Ms. Elma Loma P, Coloso, Chief Nurse, Cotabato Regional Medical Center; Ms. Maria Kristine G. Portaje, Nurse V, Cotabato Regional Medical Center, Ms. Bai Sittie Abrala L, Mamadra, Chief Nurse, Cotabato Sanitarium; Ms. Ella June C. Delos Reyes, Chief Nurse, Adela Serra Ty Medical Center; Ms, Mercy A. Yandra, Chief Nurse, Caraga Regional Hospital Moreover, we would like to extend our thanks to all HFDB Advisers and Staff who contributed to the text and procedures, write and highlight sections that may have been unclear Ms. Madeliene Gabrielle M. Doromal, Medical Social Work Adviser; Dr. Anthony B. Cu, Medical Officer V; Ms. Faye Diana C. Chua, Pharmacy Adviser, Ms. Josephine L. Guiao, Dietary Adviser, Ms, Angelita O. Jimenez, Laboratory Adviser, Ms. Chrys Abigail Paita, Focal Person for Hospital Health Information Management; Ms. Karen Joy Gregorio, Focal Person for Hospital Finance Service; ‘Ms. Clara Francesca Roa, IHOMP Coordinator, Ms. Joy Padrigano, DMO III; Infection Prevention Control Coordinator; Mr. Joy Jardinero, DMO III; Mr. Richard Albert Ramones, Medical Technologist IL Mr. Roderick M. Napulan, DMO IV; Mr. Erickson Feliciano, DMO IV; Ms. Dianne Melody De Roxas, DMO IV; Mr. Glen Cruz, DMO III; ‘Mr. Learsi Ray Afable, DMO Ill; ‘Mr. Armando Suite, DMO III; Mr. Michael Macapallag, Administrative Officer IV; Ms. Laika S. Guerrero, Administrative Assistant V; Mr. Henry Ryan Dominic G. Cajandig, Administrative Assistant III; Ms. Lea A. Erlandez, Administrative Assistant VI; Ms. Camille Ann C. Ople, Senior Administrative Assistant Il; Mr. James Bryan B. De Guzman, Research Fellow Ms, Rhod-Ann Lebrino, Administrative Assistant IIT; Mr. Ricky Ocampo, Maintenance HOSPITAL NURSING SERVICE ADMINISTRATION MANUAL TECHNICAL WORKING GRoUur. He lyS ZENAIA I. VILLALUNA, RN, MAN, Es Chairperson Development Management Officer 1V (DMO IV) ‘Nursing Adviser Health Facility Development Bureau Members: DAISY L. LLARENAS, RN, MAN Chief Nurse, National Children’s Hospital EVELYN. MONSANTO, RN, PhD Chief Nurse, Zamboanga City Medical Center AMOR B. CALAYAN, RN, PhD Chief Nurse, Batangas Medical Center FLORDELIZA R. BOBILES, RN, MAN Chief Nurse, [locos Training and Regional Medical Center mee VILMA L. COMODA, RN, PhD Chief Nurse, Southern Philippines Medical Center 5 LAURA LIBUNAO, RN, PhD Chief Nurs¢, Philippine Orthopedic Center JO§ ‘M, DATUD, RN, MSN Chief Nurse, Baguio General Hospital and Medical Center MARYBETH\E. MARCIAL, RN, MN OIC-Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital HOSPITAL NURSING SERVICE ADMINISTRATIONMANUAL Technica: CONTRIBUTORS > J NORE BENCAuas, a, Pro. now, a, MAN, Ea. Chet tune 2 Memeiei MedioatCen'e Fs én Mud ol Center ft Cowl MR MERCY C. CORAL RH, BHA, MAN PINKY MIRIAM CANLAS, RN, MAN ehref act Chef None Bavan Regioral medical Contor Br Poane I, Genco pera Resenvch osetia fe" pee SOUS, RHODOWA Q/ QULAKITIP, RN, AKAN chet fh 6 AUCHA N, SALAMANCA, RN. ALAN Siust Nese J Chiat Sease Rogier 1 Modkizel Gev'er Jose Resear mice Center Sone aft ‘SHEILA MIRA, RN, ALAN civita WEAR, en, mane Asian Coiet Num hy Executive Sector Ht Norther Mindanao sedical Venter Lung Santor af es Puiipoines Glue nesefatioa tn wan ferererethans SSenowswemotnived 9 Center ACN - ANSAP- AONE - cIRS - cMPs - CN - co. - COH - cal - csc - csR DAR - DMO. - DOH - DPO - ERM - EOQ - FMEA - Gsis. - HAMA - LIST OF ABBREVIATIONS Assistant Chief Nurse Association of Nursing Service Administrators of the Philippines Administrative Order American Organization of Nurse Executives Critical Incident Reporting System Chief of Medical Professional Staff Chief Nurse Capital Outlay Chief of Hospital Continuous Quality Improvement Civil Service Commission Central Supply Room Data Action Response Development Management Officer Department of Health Department Personnel Order Enterprise Risk Management Economic Order Quantity Failure Mode and Effect Analysis Government Service Insurance System Home Against Medical Advise HCW - HEPO - HFEP - HRD - HRM - HIA - JOM - rm = IPPA JCAHO - LDI- LGU - LIPH MCC - MOOE - MRI - NCH - NICU - NLPGN- OE * oP - PDP - PE - Hospital as Center of Wellness Health Care Workers Health Education Promotion Officer Health Facility Enhancement Program Human Resource Development Human Resource Management Health Technology Assessment Institute of Medicine Infection Prevention Control Inspection, Percussion, Palpation and Auscultation Joint Commission on Accreditation of Health Care Organization Learning and Development Intervention Local Government Unit Local Investment Plan for Health Medical Center Chief Maintenance and Other Operating Expenses Magnetic Resonance Imaging Nursing Care Hours Neonatal Intensive Care Unit National League of Philippine Government Nurses Organizational Effectiveness Organizational Performance Philippine Development Plan Physical Examination PHICS PhilHealth PHC PHU PNA PNDF PPP PS PSI QP Qos QM RA SDN TA TQM UHC UDDS Philippine Hospital Infection Control Society Philippine Health Insurance Primary Health Care Public Health Unit Philippine Nurses Association Philippine National Drug Formulary Primary Health Care, Promotion of Health, Prevention of Diseases Personnel Services Patient Safety Indicator Quality Improvement Plans Quality Management System Quality Management Republic Act Service Delivery Network Technical Assistant Total Quality Management Universal Health Care Unit Drug Dose System TABLE OF CONTENTS Authorization Message Foreword Preface Acknowledgement List of Abbreviation List of Tables List of Figures List of Appendices PART I - THE ADMINISTRATION OF NURSING SERVICES 1 ‘THE DEPARTMENT OF HEALTH Vision Mission Core Values Strategic Goals 2 THE NURSING SERVICE, Vision Mission Philosophy Core Values Strategic Goal Philosophy and Objectives of the Nursing Service Conceptual Framework Nursing Service Standards, Policies and Procedures The Philippine Professional Nursing Practice Standards Development of Nursing Standards in the Philippines Nursing Service Policies ‘The Nursing Service Policy Manual Nursing Procedures Advantages of Sound Personnel Practices in Nursing Service Administration 3. PLANNING THE NURSING SERVICE Importance of Planning Characteristics of a Good Plan Page iti iv vii viii ix wii xwvii xvii pox "W 12 12 12 12 12 1B 17 17 17 19) 20 21 23 25 25 26 TABLE OF CONTENTS ¢eontinuea) Types of Planning Kotter's 8-Step Change Model Steps in Strategic Planning Steps in Planning the Nursing Service Tools in Planning SWOT Analysis Pestel or Pestle Analysis, STEEPLE Analysis Balanced Scorecard Budgeting for the Nursing Service Project Planning ORGANIZING THE NURSING SERVICE Purposes of Organizing Organizing Principles Nursing Service as an Organization ‘The Organizational Structure of the Nursing Service Organizational Chart and its Implication Organizational Effectiveness Organizational Culture Teamwork Team Building Nursing Service Committees STAFFING IN THE NURSING SERVICE Principles of Staffing Factors Affecting Staffing Patient Care Classification System Staffing Methods Staffing Formula Shift Options Scheduling ‘Assignment Job Description DIRECTING THE NURSING SERVICE, Principles of Directing Characteristics of Directing Elements of Directing Supervision Problem Solving and Decision Making Delegation ‘Communication, Teamwork and Coordination Motivation Page 26 27 29 33 34 35 39 40 41 43 47 49 49 50 51 51 33 59 60 61 62 6 65 66 66 67 n 74 78 76 B 719 81 82 83 83 83 88 89 93 104 TABLE OF CONTENTS (continued) CONTROLLING THE NURSING SERVICE Controlling Guidelines for the Nursing Service Administrator Control Measures Utilized by the Nursing Service Administrators Performance Appraisal Performance Management System (PMS) Recording and Reporting Employee Discipline Employee's Code of Conduct Disciplinary Conference Due Process Handling Complaints Conflict Management Change Management PART II — THE MANAGEMENT IN THE DELIVERY OF NURSING 8 10 CARE SERVICES NURSING PROCESS Introduction Purposes of the Process Benefits of the Nursing Process Steps of the Nursing Process Nursing Assessment Nursing Diagnosis, Nursing Planning and Outcome Identification Nursing Implementation Nursing Evaluation Moba ities oF CARE Introduction Functional Nursing Total Care or Case Nursing Primary Nursing Team Nursing QUALITY MANAGEMENT Introduction Definition of Terms Principles of Total Quality Management Strategies in Total Quality Management Quality Improvement Plans (QIP) Work as Systems and Processes The Role of Organizational Leadership Quality Improvement Program Page 107 109 110 110 113 116 7 7 118 119 120 122 127 129 131 131 131 132 132 132 133, 133 134 134 137 137 138 139) 140 141 143, 143 144 146 146 147 149 150 151 iu 12 ABLE OF CONTENTS (continued) ‘Nursing Quality Improvement Continuous Quality Improvement (CQI) The PDCA or PDSA Cycle Roles of Nursing Leaders Methods of Nursing Audits Quality Circle Quality Assurance SAFETY IN HEALTH CARE Introduction Definition of Terms Key Elements of Patient Safety Ten (10) Reasons for Global Patient Safety Strategies that Promote Patient Safety ‘Types of Errors Medication Errors ‘The Nurse’s Responsibility for the Patient's Safety Emergency Care Consent (Right to Informed Consent) Therapeutic Orders ‘The Generics Act Law (RA 6675) Medication Rights Indicators and Parameters of Safety Nursing Actions to Improve Patient Safety Implementing Policies on Accidents Patients’ Safety Implementing Policies Occupational and Environmental Health Nursing, Infection Prevention and Control (IPC) Standard Precautions Management of P: Colonization Needlestick Injury Safe Transfusion of Blood and Blood Component is with Suspected MRSA Infection or RISK MANAGEMENT Introduction Importance of Risk Management Strategies of Risk Management Clinical Risk Management Principles of Risk Management Essentials for Risk Management Program Risk Management Process Risk Identification Page 151 153 154 158 159 160 160 171 171 171 172 173, 174 178 179) 181 181 181 182 182 183 183 184 185 186 188 189 192 194 194 196 199 199 200 201 202 203 204 205 209 13, 14 15 TABLE OF CONTENTS (eontinuead Scope of the Risk Management Risk Potential Essentials of Risk Management Program Risk Management Committee Strengthening the Risk Management Program Tools and Practices Failure Mode and Effect Analysis (FMEA) NURSING INFORMATION MANAGEMENT SYSTEM Introduction Importance of Nursing Information Management Information System Hospital Information System Integrated Hospital Operations and Management Program (IHOMP) Integrated Hospital Operations and Management Information System (iHOMIS) Records Management ‘Nursing Office Records Required Patients’ Data That Needs to be Documented Nursing Documentation Nursing Kardex Discharge Against Medical Advice (DAMA) EY HICO-LEGAL IN NURSING LEADERSHIP Introduction Ethical Concems Confronting Nurses Ethical Principles Ethical Conflicts Technological Concepts and Ethical Practice Ethical Considerations in Patient Care Nurse’s Legal Responsibility for Patient Care Therapeutic Orders Causes of Malpractice for Nurse Managers and Nurses Disciplinary Action on Errors HUMAN RESOURCE MANAGEMENT Introduction Importance of Human Resource Management Human Resource Development Program PRIME-HRM Page 21 212 213 215 215 218 220 223 223 223 223 225 226 227 229 230 234 238, 243 244 245, 245 245 246 248 249 249, 250 253 254 256 257 257 257 261 268 TABLE OF CONTENTS (continued Page 16 MANAGEMENT OF SUPPLIES AND EQUIPMENT 21 Introduction 27m Materials, Supplies and Equipment Inventory System 272 Preventive Maintenance of Equipment 273 Guidelines in the Management of Supplies and Equipment 274 Inventory 274 Stock Control 217 17 HosPrrat as PEOPLE-CENTERED HEALTH CARE 281 Introduction 281 Potential Benefits of People-Centered and Integrated Health 282 Services Key Principles in People-Centered Care 284 People-Centered Health Services 284 Perspectives in Quality 285 REFERENCES 287 Table 31 5. 53 LIST OF TABLES Differences between the Strategic Planning and Operational Planning, Classification of Patient Care by Units, Nursing Care Hours/ Patient/Day and Ratio of Registered Nurses to Non-Professional Staff Needed Classification of Patients by Levels of Care, Nursing Care Hours/Patient/Day and Ratio of Professionals to Non- professionals Needed Classification of Patients by Levels of Care according to Type of Hospital with Percentage of Patients at Various Levels of Care Nursing Staffing Standards for Government Hospitals Total Number of Working days, Non-Working days and Working Hours of Nursing Personnel per Year Personnel Staffing Schedule: Fight-Hour Shift Likelihood Seale Loss or damage impact scale Risk Priority Seale owvil Page 28 68 69 70 208 Figure 1d 12 21 2.2 3.1 32 33 34 35 41 42 43 7A 12 81 OL 9.2 93 94 10.1 10.2 10.3 10.4 12.1 12.2 12.3 LIST OF FIGURES FI Plus Strategy Map DOH Funetional Management Team ‘The Nursing Management System ‘The Nursing Management Process Five-Step Process in Succession Planning Example # 1 of SWOT Analysis Example #2 of SWOT Analysis Example of Pestel or Pestle Analysis Framework of Balance Scorecard Organizational Chart Organizational Structure Showing the Relationships of the Nursing Service with the College of Nursing Functional Structure of the Nursing Service Showing Levels of Position Performance Management System Cycle Steps of Progressive Discipline The Nursing Process Functional Nursing Care Delivery Model Total Patient Care Nursing Delivery Primary Nursing Care ‘Team Nursing Care Inputs, Processes and Outputs/Outcomes Quality Improvement in Practice Quality Improvement in Nursing Nursing Quality Indicators Risk Management Risk Management Process Risk Management Steps Page 120 135 138 139 140 142 149 156 157 157 204 206 210 Figure 12.4 141 15.1 Risk Management Principles Ethical Decision Making Framework Recruitment and Selection Process Page 2u1 247 258 Appendix mt aonmuvuawsa e2@

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