STANDARDS OF NURSING SERVICES

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The first part is Clinical Services. This component focuses on defining what the standards are in the clinical setting. I. Standards on Assessment of Care -include the process and scope and content of assessment. II. Standards on Care of Patient.

- There are seven (7) identified criteria that identify care process, care plan, implementation of care and evaluation of care rendered.
III. Standards on Patient and Family Education
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independent role in providing health

The second part is the Administration and Management. This concerns managing the nursing services in the hospital. There are five (5) standards identified:

I. Standards on Governance and Direction. - This chapter recommends the need for organizational structure which will delineate responsibility, accountability and authority of nursing administration. II. Standards on Human Resource Management. - placing the right person to do the right job through identification of the job requirements and qualifications III. Standards on Facility Management and Environmental Safety - This standard contains three (3) criteria and covers environmental safety needed in the delivery of nursing services and training of personnel to effectively carry out their respective roles.
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A. Standards on Assessment of Care

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Measurable Elements

Standard 1A: Assessment Process

1.

There is an evidence of initial and completion of nursing assessment on the health care needs of each patient. There is an evidence of patients reassessment throughout the care process to determine response to intervention at interval appropriate to patients condition, plan of care, individual needs or according to institutional policies and procedures. Those responsible for direct nursing care collaborate with medical and allied staff to analyze and integrate the patients assessment data and information. Those responsible for direct nursing care prioritize patients needs based on assessment results.
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1.

2.

3.

4.

Those responsible for direct patient care inform the patient

Standard 2A: Assessment Scope & Measurable ElementsContent

1.

There is a well defined policy on nursing assessment in terms of scope and content which include but are not limited on the following:

Psychological Social Economic Factor Vital Signs

- Physical - Spiritual - Health History - Pain Assessment

Nutritional status, needs, and risks - Preference and idiosyncrasies Discharge Plan

2.

There is an established screening criteria according to patients functional capacity and needs like: 7/22/12

3. The care plan reflects the related and relevant identified needs and problems of each patient cared for.

4. The care plan ensures that priorities of care are established.

5. The care plan is updated as appropriate based on the reassessment made.

6. The care plan is documented in the individual patients record to promote continuity of care.

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B. Standards on Care of Patient

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Standard 1B: Care Process Measurable Elements

1.

There are existing policies and procedures on care process developed by those responsible for governance which include but are not limited on the following:

1.1. Care of emergency patients (including use of resuscitation equipment) 1.2. Care of patient on life support (e.g. ventilatory equipment) 1.3. Care of patient on dialysis (hemodialysis, peritoneal dialysis) 1.4. Care of patients at risk: Neonates Children 7/22/12 Elderly Disabled

Standard 2B: Care Plan

Measurable Elements
There is a written care plan on every patient cared of by the nurse based on patients initial assessment data within the 1st 24 hours of assessment or earlier.
1.

2. There is an evidence that family and significant others are involved in the planning process. 2.1. Patient participate in planning of care taking into consideration the cultural, religious and other beliefs of patients. Example: Selection of food

3. The care plan reflects the related and relevant identified 7/22/12 needs and problems of each patient cared for.

Standard 3B: Implementation of Care Measurable Elements

1.

There is an evidence that nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical judgment based on but are not limited on the following:

1.1. Scope of Nursing Practice as provided by lawand all relevant legislations (e.g. The Philippine Nursing Act of 2002 or Republic Act 9173) 1.2. Standard of Care 1.3. Evidence - based practice 1.4. Ten (10) Golden Rules in Drug Administration 1.5.Code of Ethics for Nurses

1.6. 7/22/12 Patient Bill of Rights

Standard 4B: Evaluation of Care Measurable Elements

1.

Systematic and continuous evaluation of patients progress and effectiveness of care is reflected in the individualized patient record.

2. There is an evidence that evaluation of care and patient outcome occurs within an appropriate time frame after the intervention (nursing or medical) is initiated.

3. There is an evidence that interventions are documented.

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patients

responses

to

Standard 5B: Pain Management Measurable Elements

1. There is an existing pain management guideline for nurses to appropriately assess, monitor, evaluate and manage patients in pain.

2. There is evidence that patients receive care according to pain management guidelines.

3. There are existing education and training programs for nurses on pain management. 7/22/12 4. Processes to communicate with and evaluate patients and families

Standard 6B: Medication Management

Measurable Elements

1.

There are written policies, procedures and guidelines on medication management which include but are not limited on the following:

1.1.Carrying out physicians medication order 7/22/12

1. Respect for patients values, religion and cultural preferences and practices is evident.

Standard 7B: End-of-Life Care

1.1. Pastoral services are provided based on the spiritual beliefs of the patient and family. 1.2.The patients right of selfdetermination and choices are respected and accommodated.

1.3.Advance directives Do Not 7/22/12 Resuscitate, Waiver, Living will if any,

Standard 8B: Patient and Family Rights

1.

These are written policies, processes and guidelines that respect and support patient and family rights.

1.1. Prerogative to determine what information regarding health condition and care is providedto family and under what circumstances. 1.2.Respect for patients personal values and beliefs 1.3.Respect the confidentiality of patient health information 1.4.Respect for patients need for privacy (e.g. during treatment, procedure, physical examination, clinical interview, transport) 1.5. Protection of patients possessions from theft or loss 1.6. Protection of patient from physical assault (e.g. vulnerable patients are infants, children and elderly)

1.7. 7/22/12 Support patient and family rights by participating in the care decision and care process through information

C. Standards on Patient and Family Education

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Standard 1C: Education Assessment

Measurable Elements There is a written evidence that the nurse assesses the educational needs of each patient and family which include but are not limited on the following:

1.

1.1. Patients and familys beliefs and values 1.2. Patients and familys literacy 1.3. Patients and familys educational level 1.4. Patients and familys language

1.5. 7/22/12 Patients and familys motivations and emotional barriers

Standard 2C: Education Plan and Programs

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Measurable Elements
1. The educational plan and programs for patient and family are evident according to the type of patient served and his/her learning needs. 2. The appropriate structure, methods and mechanism for education is afforded.

3. Education resources are available and organized in an efficient and effective manner.

4. When appropriate, it is evident that the patient and family are educated on topics considered high risk to patients:

4.1. Safe and effective use of medications and their side effects 4.2. Preventing interactions between prescribed medications and other medications (over the counter) and food 4.3. Safe and effective use of medical equipment 4.4. Pain management 4.5.Rehabilitation techniques

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D. Standards on Access and Continuity of Care

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Standard D1: Access to Care

Measurable Elements 1. The written policies and processes on patient access to care are evident which include but are not limited on the following:

1.1. Clinical services available

1.2. Triage or screening There is evidence that triaging or screening is 7/22/12 initiated at the point of 1st contact with

Standard 2D: Emergency Patients

Measurable Elements
1. There is an evidence that patients with immediate needs/care are assessed, prioritized and received the necessary care as quickly as possible according to established physiologically based criteria.

2. There is an evidence that staff who responded to emergency patients underwent the necessary training.
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Standard 3D: Admitted Patients or In-Patients

Measurable Elements 1. There is an evidence that nurse screening assessment focuses on preventive, curative, rehabilitative and palliative services and prioritizes these according to the patients health condition.
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Standard 4D: Intensive and Specialized Services

Measurable Elements 1. There is an evidence of entry/or transfer criteria for patients that need intensive and specialized services to meet special patient needs. 2. It is evident that criteria is physiologic-based and developed by 7/22/12

Standard 5D: Continuity of Care

Measurable Elements 1. The written policies and processes on patient continuity of care are evident and implemented throughout all phases of patient care particularly but are not limited in the following services:
1.1.Emergency services to nursing ward 7/22/12 admission

Measurable Elements

Standard 6D: Discharge, Out on Pass, Referral and Follow-up

1. There are written policies, procedures and guidelines on patients discharge, out on pass, referral and follow-up congruent with those of the organization. 2. There are criteria that determine patients readiness to be discharged.
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6. A copy of patients discharge summary is placed in the patient record and another copy is given to the patient which include but are not limited on the following:

6.1.Reason for admission 6.2. Significant physical and other findings 6.3. Significant diagnosis and comorbidities 6.4.Diagnostic and therapeutic

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Standard 7D: Transfer of Patient

Measurable Elements 1. There is a written policy, procedure and guidelines on transfer of patient within and outside of the organization. 2. The guidelines and procedures include but are not limited on the following:
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2.1.Transfer is based on the patients

E. Standards on Nursing Documentation

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Standard E1: Structural Data

Measurable Elements 1. There is an accurate and complete documentation of patients structural data in all nursing and applicable forms which include but are not limited on the following:

1.1. Patients addressograph name, age, gender, civil status 1.2. Registration number and or

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Standard 2E: Clinical Data

Measurable Elements 1. There is relevant/essential, accurate and complete nursing documentation of patients clinical data in all appropriate forms from admission to discharge in health care facility which include but are not limited on the following:
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1.1. Physical examination (head-to-toe)

PART II: ADMINISTRATION & MANAGEMENT

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A. Standards on Governance and Direction

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Standard 1A: Governance Structure

Measurable Elements The Nursing Services governance structure is represented or displayed in an organizational chart that shows functional and positional relationships and span of control.

1.

2. The Nursing Services governance 7/22/12

Standard 2A: Governance Responsibility and Accountability Measurable Elements

1. The governance responsibility and accountability are described in organizations by laws, job description and other similar documents. 2. Those responsible and accountable for governingand managing the Nursing Services Department are 7/22/12 identified by position title and name.

Standard 3A: DirectionSetting

Measurable Elements Those responsible for the Nursing Services Department governance, primarily sets its direction by formulating its vision, mission, philosophy, core values and quality objectives congruent with that of the institution and the Nursing 7/22/12 profession.

1.

Standard 4A: Strategic & Operational Plans

Measurable Elements 1. Those responsible for governance forecast and direct the future and operation of the Nursing Services Department in order to achieve its overall goals. 2. There is an existence of strategic 7/22/12

Measurable Elements

Standard 5A: Financial Plan & Resource Allocation

1. Those responsible for governance have established current financial plans and allocation of resources based on the needs of the Nursing Services Department. 2. The capital and operating budgets 7/22/12

Standard 6A: Policies & Procedures Development

Measurable Elements 1. Those responsible for governance develop and implement policies and procedures based on established Standards of Nursing Administration and Nursing Service on Patient Care.

2. An updated manual of Nursing Services policies and procedures exists and provides clear directive for nursing personnel at different levels on the scope and limitations of their functions and responsibilities to patient care.

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Measurable Elements

Standard 7A: Ethico Moral & Legal Accountabilities

1. Those responsible for governance formulate policies and procedures to serve as guidelines for those confronted by ethico-moral dilemmas in patient care. 2. Those responsible for governance ensure compliance with the applicable 7/22/12 statutory laws, regulations and

Standard 8A: Professional & OrganizationalInvolveme nt Measurable Element:

1. Those responsible for Nursing Services Department governance initiate and maintain formal liaison/linkage with other departments/sections of the institution and professional associations and agencies pertinent to nursing standards and practices, professional and interprofessional relationships and other related endeavors.

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B. Standards on Human Resource Management

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Measurable Elements

Standard 1B: Administrator of Nursing Services

There are presence of evidences that the Nursing Service Administrator is qualified to the position based on RA 9173 and other criteria set by the organization/institution.

1.

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Standard 2B: Staffing Plan

Measurable Elements 1. Those responsible for Nursing Services governance develop a staffing plan that identify the number, type and desired qualification (education, skills and experience) of Nursing Services staff, reviewed and updated on an ongoing basis.
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Measurable Elements

Standard 3B: Recruitment, Selection, Hiring and Appointment

1. Those responsible for the Nursing Services governance actively participate/collaborate in the development of system and processes for recruitment, selection, hiring, appointment and promotion of nursing service personnel in accordance with 7/22/12 the statutory laws and regulations and

Standard 4B: Credentialing

Measurable Elements 1. Those responsible for Nursing Services governance develop an effective process for gathering, verifying and evaluating the nursing staff credentials (licensure, education, training, work experience) and other pertinent requirements.
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Standard 5B: Staff Placement

Measurable Elements 1. Those responsible for Nursing Services governance develop and define the criteria (core competencies) and processes to match the clinical staff knowledge and skills with the patients needs.
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Standard 6B: Staff Job Description

Measurable Elements 1. There is a written Job Description for each position classification of Nursing Services personnel which specifies:

1.1. Duties and responsibilities 1.2. Accountability 1.3. Functional relationship Qualification and experience

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Standard 7B: Staff Development

Measurable Elements 1. Those responsible for Nursing Services governance design and implement staff development programs for nursing personnel at all levels based on training needs analyses.
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3. Resources are available to implement the staff development program such as:

3.1. Space and facilities 3.2.Educational resources 3.3.Clinical and clerical staff 3.4.Audiovisual equipment 3.5.Resource speakers

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4. Policies and procedures on

C. Standards on Facility Management & Environment Safety

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Standard 1C: Facility Planning

Measurable Elements 1. Those responsible for governance comply with relevant laws, regulations and other requirements that are applicable. 2. Those responsible for governance actively participate in space planning 7/22/12

Standard 2C: Environmental Safety

1.

There is a written and up-to-date plan, implementation and evaluation of programs/activities to manage the risks within the environment which includes but is not limited on the following:
1.1. Safety and Security 1.2.Hazardous Materials and Waste 1.3.Medical Equipment 1.4.Utilities

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Standard 3C: Staff Education

Measurable Elements

1. There is an evidence of staff education and training on facility management and environmental safety programs. 2. There is an evidence that the staff can describe and demonstrate their 7/22/12

D. Standards on Communication Management

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Standard 1D: Communication of Information

Measurable Elements
1.

There is efficient and effective system of communication that exist which include but are not limited on the following:

1.1.Community 1.2. Patients and Families 1.3.Nursing Personnel 1.4.Other Health Professionals (clinical and nonclinical staff)

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Standard 2D: Patient Clinical Record

Measurable Elements There are written policies, procedures, and guidelines on patient clinical record which include but are not limited on the following:

1.

1.1.Clinical record for every patient assessed or treated, in-patient or out7/22/12 patient

Standard 3D: Administrative Record

Measurable Elements
1.

There is a written policy or protocol in keeping and maintaining Nursing Services Department administrative records.

2. There is written policy or protocol in developing and maintaining policies and procedure.

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E. Standards on Quality Improvement

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Standard 1E: Leadership and Measurable Elements Staff Education

1. Those responsible for governing and managing the Nursing Service Department lead or actively participate in planning, monitoring, analyzing and implementing quality improvement and patient and staff safety programs congruent with the organizational needs.

2. There is an evidence that information on quality improvement and patient and staff safety programs are communicated to staff on a regular basis through effective channels inclusive of progress on compliance.

3. There is a training program for staff consistent with their role in quality improvement and patient safety program.

4. There is a qualified trainer who provides the training and staff participation as part of their regular work assignment.

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Standard 2E: Quality Programs

Measurable Elements 1. There is written plan or policy or document of a well designed new processes or modified existing processes consistent with current practice, guidelines, clinical standards, scientific literature, and other relevant evidence based information.
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(e.g. Medication safety, clinical

Measurable Elements

Standard 3E: Quality Monitoring, Analysis & Implementation

1. There is a clinical monitoring that exists. 2. There is a managerial monitoring that exists
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