Standards of Nursing Services ANSAP

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STANDARDS OFNURSING SERVICES

Association of Nursing Service Administrators

of the hi!i""ines# Inc$

%ANSA&

Committee on Nursing Practice

'(() Edition



STANDARDS OFNURSING SERVICES

All rights reserved. All works herein are properties of

ANSAP and no part of this book may be copied,reproduced or published in any form without the proper

consent of the authors and publishers.



FORE*ORD

This publication is designed to provide nursingadministration a guide reference in managing nursing services.It also reflects the ANSAP’s deep commitment in improving thequality of patient care and management of nursing services in thePhilippines.

The development was actively participated by the oardof Nursing !P"#$%N& and the ANSAP’s oard of 'irectorsand validated by the #hief Nurses(Nursing 'irectors who arealso members of ANSAP. The initial draft was eventuallyreviewed and discussed by opinion leaders in focus group of e)perts. The final blueprint was presented to public hearingattended by *ey sta*eholders around the country.

This edition contains a complete set of standards

presented in two ma+or components namely, the #linical andAdministration management. -ach component has five

standards criteria and measurable elements necessary to helporgani/ations educate the staff.

This edition is also a cross$reference to corresponding

requirements set forth in the Philippines by ANSAP and theinternational accrediting body li*e 0oint #ommissionInternational !0#I&.

1e view that standards are continuously a wor* in progress. 2ence we welcome any comments and suggestionsfor improvement.

TA+,E OF CONTENTS

IntroductionC!inica! Services

I. Standards on Assessment of CareStandard I. Assessment Process

Standard II. Assessment Scope and #ontent

II. Standards on Care of Patient

Standard I. #are Process

Standard II. #are Plan

Standard III. Implementation of #are

Standard I3. -valuation of #are

Standard 3. Pain 4anagementStandard 3I. 4edication 4anagement

Standard 3II. -nd$of$5ife #areStandard 3III. Patient and 6amily "ights

III. Standards on Patient and Family Education

Standard I. -ducation Assessment

Standard II. -ducation Plan and Programs

IV. Standards on Access and Continuity of Care

Standard I. Access to #areStandard II. -mergency Patients

Standard III. Admitted Patients or In$PatientsStandard I3. Intensive and Speciali/ed Services

Standard 3. #ontinuity of #are

Standard 3I. 'ischarge %ut on Pass "eferral and 6ollow$up

Standard 3II. Transfer of Patient

V. Standards on Nursing Documentation

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



needed in the delivery of nursing services andtraining of personnel to effectively carry out their

respective roles.

3. Standards on Nursing Documentation. There are

two identified criteria under this component whichinclude documentation of significant data both

structure and clinical based on applicable laws andregulations professional standards and institutional

requirements.

The second part is the Administration and 4anagement.This concerns managing the nursing services in the hospital.There are five !=& standards identified;

I. Standards on Governance and Direction. There

are seven !<& criteria included. This chapter recommends the need for organi/ational structurewhich will delineate responsibility accountabilityand authority of nursing administration. These focusalso on planning direction organi/ation andcontrolling functions of the nursing serviceadministration and their relationship with other services.

II. Standards on /uman Resource -anagement.This part contains five !=& criteria which help thenursing administrators in placing the right person todo the right +ob through identification of the +ob

requirements and qualifications. It also includesstaffing modalities depending on the type of services.

III. Standards on Faci!it. -anagement and

Environmenta! Safet.. This standard contains

three !>& criteria and covers environmental safety

I3. Standards on Communication -anagement.

Three !>& criteria are identified focusing on the patient’s record administration record andcommunication of information. It also enables thechief nurses(administrator to develop a specifichospital system which is efficient and effective.

3. Standards on 0ua!it. Im"rovement. This

standard has three !>& criteria which address theneed to institutionali/e continuous quality and

performance improvement.

-ach standard and criteria has identified measurableelements intended to provide clarity to the standards and to help

organi/ations develop their own policies and proceduresaccording to the standards.



C,INICA, SERVICES

I$ Standards on Assessment of Care

S t andard I # Assessment Process

The nurse identifies the health care needs of each patient

based on an established assessment process and within the prescribed timeframe.

Measura$le Elements

?. There is an evidence of initial and completion of nursing assessment on the health care needs of each

patient within the;

1.1.?st

@ hours of admission as an in$patient or

earlier as indicated by the patient’s condition or institutional policy.

1.2.?

st

@ hours of consultation as an outpatient or earlier as indicated by patient’s condition or institutional policy.

@. There is an evidence of patient’s reassessmentthroughout the care process to determine response to

intervention at interval appropriate to patient’scondition plan of care individual needs or

according to institutional policies and procedures!e.g. Pain is assessed every hours and as necessary

as part of the vital signs monitoring&.

>. Those responsible for direct nursing care collaboratewith medical and allied staff to analy/e and integrate

the patient’s assessment data and information.. Those responsible for direct nursing care prioriti/e

patients’ needs based on assessment results.

=. Those responsible for direct patient care inform the patient and family of the assessment outcome andthe planned care and treatment regimen andencourage participation of the latter in the decision$ma*ing about the priority needs to be met.

S t andard I I # Assessment Sco"e % Content

The scope and content of nursing assessment are welldefined in an institutional policy wherein those elements

common to all assessments and any differences with other

health disciplines are identified.

Measura$le Elements

?. There is a well defined policy on nursing assessmentin terms of scope and content which include but arenot limited on the following;

1.1. Psychological

Bnowledge level

5anguage spo*en

arriers to learning

?.@. Physical

Neurological assessment

#ardiovascular assessment

"espiratory assessment

7astrointestinal assessment

7enitourinary assessment

4usculos*eletal assessment

Intergumentary assessment



Sensory assessment?.>. Social

#ultural concerns?.. Spiritual

"eligion?.=. -conomic factor

6inancial barrier

?.C. 2ealth history

'evelopmental history !for pediatrics&

6amily history

4edications ta*en

Allergies?.<. 3ital signs

?.D. Pain assessment?.E. Nutritional status needs and ris*s?.?F.Preference and idiosyncrasies

?.??.'ischarge plan

Place; home e)tended s*illed carefacility

Individual who will accompany the patienthome !name address telephone number

relationship&

@.??.3alue 8 elief Pattern>. %ther pertinent data are collected using the

appropriate assessment technique and instruments.

. The nursing assessment findings are documented in

the individual patient’s record and readily availableto those responsible for his(her care.

=. 'ischarge plan is evident in the initial assessment of the nurse particularly to those patients whendischarge planning is critical as evidenced by thefollowing;

=.?. Age=.@. 5ac* of mobility

=.>. #ontinuing medical and nursing needs=.. Assistance with activities of daily living=.=. "eferral for continuity of care as necessary

II$ Standards on Care of atient

S t andard I # Care Process

The Nursing Services 'epartment has an established@. There is an established screening criteria according

to patients’ functional capacity and needs li*e;

@.?. Nutritional 8 4etabolic Pattern@.@. -limination Pattern@.>. Activity 8 -)ercise Pattern

uniform care process across the clinical setting that reflects

integration and coordination of care of other health team

members particularly to those patients with similar condition.

@.. Sleep 8 "est Pattern@.=. Se)uality 8 "eproductive Pattern

Measura$le Elements

@.C. Sensory 8 Perceptual Pattern ?. There are e)isting policies and procedures on care@.<. #ognitive Pattern process developed by those responsible for @.D. "ole 8 "elationship Pattern governance which include but are not limited on [email protected]. Self 8 #oncept Pattern following;@.?F.#oping 8 Stress Tolerance Pattern



?.?. #are of emergency patients !including useof resuscitation equipment&

?.@. #are of patient on life support !e.g.ventilatory equipment&

?.>. #are of patient on dialysis !hemodialysis

peritoneal dialysis&

?.. #are of patients at ris*;

1. There is a written care plan on every patient cared of by the nurse based on patient’s initial assessment

data within the ?st

@ hours of assessment or earlier.@. There is an evidence that family and significant

others are involved in the planning process.@.?. Patient participate in planning of care ta*ing

into consideration the cultural religious andother beliefs of patients. -)ample;Selection of food

Neonates

#hildren

-lderly

'isabled

#ritically$ill

4entally disadvantaged

:nder anesthesia

>. The care plan reflects the related and relevantidentified needs and problems of each patient caredfor.

. The care plan ensures that priorities of care are

?.=. #are of comatose patient?.C. #are of patient with communicable diseases?.<. #are of patient in restraint

?.D. #are of patient on chemotherapy?.E. #are of immune $ suppressed patients

?.?F. #are of patient in pain?.??. #are of patient on nutritional therapy?.?@. #are of patient receiving blood and blood

components?.?>. #are of patient receiving medications with

narrow margin of safety?.?. #are of perioperative patient?.?=. #are of patient with intravenous therapy

S t andard I I # Care Plan

The nurse caring for patients develops and updates anindividuali/ed written care plan in the patient’s record withinthe prescribed time frame.

Measura$le Elements

established.=. The care plan is updated as appropriate based on the

reassessment made.

C. The care plan is documented in the individual patient’s record to promote continuity of care.

S t andard I II # Im"lementation of Care

The nurse caring for patients implements nursing

intervention and carries out medical orders utili/ing criticalthin*ing and sound clinical +udgment for the promotion of

health prevention of illness alleviation of suffering andrestoration of health.

Measura$le Elements

?. There is an evidence that nurse caring for patientsimplements nursing intervention and carries outmedical orders utili/ing critical thin*ing and soundclinical +udgment based on but are not limited on thefollowing;



?.?. Scope of Nursing Practice as provided bylaw and all relevant legislations !e.g. The

Philippine Nursing Act of @FF@ or "epublic ActE?<>&

?.@. Standard of #are;

Acute and #ritical #are Nursing Practice

#hronic #are Nursing Practice

#ardiovascular Nursing Practice

Perioperative Nursing Practice

4aternal and #hild Nursing Practice

Psychiatric Nursing Practice-mergency Nursing Practice

"enal Nursing Practice

Pediatric Nursing Practice

%ncology Nursing Practice

7eriatric Nursing Practice

-thical and 5egal Nursing Practice

Nursing Standard on Intravenous Therapy

Infection #ontrol Nursing Practice?.>. -vidence $ based practice?.. Ten !?F& 7olden "ules in 'rug Administration

?.=. #ode of -thics for Nurses?.C. Patient ill of "ights

@. It is evident that implementation of interventions(care is delivered in a safely manner that minimi/es complications and life$threatening

situations.

S t andard I V # Ealuation of Care

The nurse caring for patients systematically andcontinuously evaluates the patient’s progress based on the

effectiveness of nursing intervention rendered and medicalmanagement provided.

Measura$le Elements

?. Systematic and continuous evaluation of patient’s progress and effectiveness of care is reflected in theindividuali/ed patient record.

@. There is an evidence that evaluation of care and

patient outcome occurs within an appropriate time

frame after the intervention !nursing or medical& isinitiated.

>. There is an evidence that patient’s responses tointerventions are documented.

. The revision in care plan if any is reflected in the patient record.

S t andard V # Pain Management

The Nursing Services 'epartment has established painmanagement guidelines for nurses to appropriately assess

monitor evaluate and manage patients in pain.

Measura$le Elements

?. There is an e)isting pain management guideline for nurses to appropriately assess monitor evaluate and

manage patients in pain.@. There is evidence that patients receive care

according to pain management guidelines.



>. There are e)isting education and training programsfor nurses on pain management.

. Processes to communicate with and evaluate patientsand families about pain are evident.

S t andard V I # Medication Management

The Nursing Services 'epartment has established

policies procedures and guidelines on medicationmanagement for symptomatic curative preventive and

palliative treatment of patients’ diseases and for safe nursing practice.

Measura$le Elements

?. There are written policies procedures and guidelines

on medication management which include but arenot limited on the following;?.?. #arrying out physician’s medication order ?.@. Transcribing and ordering?.>. -ndorsing !especially high valuable drugs&?.. Preparing?.=. 5abeling

?.C. Administering !?F 7olden "ules in 'rugAdministration&

?.<. 'ocumenting?.D. 4onitoring and Storage

?.E. -mergency 'rugs?.?F."egulated 'rugs?.??.4edication "ecall System !-)pired or

%utdated 'rugs&?.?@."eporting on

4edication effects and adverse effects

4edication error and near$miss

S t andard V I I # End&of&'ife Care

The nurse provides an end$of$life care to facilitate adignified and peaceful closure of life for patients through

physiological psychological social and spiritual care ta*inginto consideration the cultural diversities in beliefs andcustoms and optimi/e caring environment.

Measura$le Elements

?. "espect for patient’s values religion and cultural

preferences and practices is evident.?.?. Pastoral services are provided based on the

spiritual beliefs of the patient and family.?.@. The patient’s right of self$determination

and choices are respected and accommodated.?.>. Advance directives 'o Not "esuscitate

1aiver 5iving will if any are respected.?.. Patient and family choices to donate organs and

other tissue are supported through provision of relevant information. In accordance to statutorylaws rules and regulations.

@. Assessment appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of patient and family and re$assessment are evident.@.?. Pain assessment intervention and

evaluation are monitored and recorded.@.@. Personal hygiene is rendered based on patient’s

need.



@.>. Nutritional assessment and ris*s areidentified and nutritional needs are provided

such as feeding and hydration.@.. Interventions address patient and

family’s psychosocial emotional spiritual and

culturalconcerns.

>. A place is designated for the patient’s family to stay.. The patient and family are involved in care

management and decision.

S t andard V II I # Patient and Family Rig(ts

The Nursing Services 'epartment has established policies processes and guidelines that respect and support patient and family rights.

Measura$le Elements

?. There are written policies processes and guidelinesthat respect and support patient and family rightswhich include but are not limited on the following;?.?. Prerogative to determine what

information regarding health condition and careis providedto family and under what circumstances.

?.@. "espect for patient’s personal values and beliefs

?.>. "espect the confidentiality of patient healthinformation?.. "espect for patient’s need for privacy !e.g.

during treatment procedure physicale)amination clinical interview transport&

?.=. Protection of patient’s possessions from theftor loss

?.C. Protection of patient from physical assault!e.g. vulnerable patients are infants childrenandelderly&

?.<. Support patient and family rights by participating in the care decision and care process through information of the following;

4edical condition and confirmed

diagnosis and the informant

Planned care treatment outcome of careunanticipated outcome and participation incare decision according to wishes

Informed consent

"efusal or discontinuance of treatment

1ithholding life$sustaining treatments

Assessment and management of pain

#ompassionate care at the end$of$life

Process on complaints and differences of

opinion about patient care

Participation in clinical research%rgan donation and other tissues

'isclosure of information@. There is evidence that nurses are *nowledgeable and

supportive of patient and family rights.

III$ Standards on atient and Fami!. Education

S t andard I # Education Assessment

The nurse assesses the educational needs of each patient

and family and documents these in his(her patient record.

Measura$le Elements

?. There is a written evidence that the nurse assessesthe educational needs of each patient and familywhich include but are not limited on the following;?.?. Patient’s and family’s beliefs and values

?.@. Patient’s and family’s literacy?.>. Patient’s and family’s educational level



?.. Patient’s and family’s language?.=. Patient’s and family’s motivations

and emotional barriers?.C. Patient’s physical and cognitive limitation?.<. Patient’s willingness to receive information

S t andard I I # Education Plan and Programs


educational plans and programs that support patient andfamily participation in care decisions and care processes

with the primary ob+ective of rehabilitating the patient bac* to his(her functional level and optimal health.

Measura$le Elements

?. The educational plan and programs for patient and

family are evident according to the type of patientserved and his(her learning needs.

@. The appropriate structure methods and mechanismfor education is afforded.

>. -ducation resources are available and organi/ed inan efficient and effective manner.

. 1hen appropriate it is evident that the patient andfamily are educated on topics considered high ris* to

patients;.?. Safe and effective use of medications and their

side effects.@. Preventing interactions between prescribed

medications and other medications !over thecounter& and food

.>. Safe and effective use of medical equipment.. Pain management.=. "ehabilitation techniques.C. Treatment and diagnostic procedures

=. It is evident that standardi/ed materials and processes in educating patient and family on theaforementioned topics !.? to .=& are available.

C. There is an evidence that nurses who provideeducation have the sub+ect *nowledge adequate

time and communication s*ills to do so.

IV$ Standards on Access and Continuit. of Care

S t andard I # Access to Care

In diverse health care setting the Nursing Services'epartment has established policies and processes on patientaccess to care aligned with the organi/ation.

Measura$le Elements

?. The written policies and processes on patient accessto care are evident which include but are not limitedon the following;

?.?. #linical services available?.@. Triage or screening

There is evidence that triaging or

screening is initiated at the point of ?st

contact with the patient?.>. #riteria for admitting patient or registering

out patient

?.. Process for admitting patient or registeringout patient

?.=. 2olding area for patient on observation?.C. 4anaging patient when bed or space or

facilities is not available

S t andard I I # Emergency Patients



The patients with emergency or immediate needs(careare given priority for assessment and treatment by the nurse.

Measura$le Elements

?. There is an evidence that patients with immediateneeds(care are assessed prioriti/ed and received thenecessary care as quic*ly as possible according toestablished physiologically based criteria.

@. There is an evidence that staff who responded to

emergency patients underwent the necessary

training.

S t andard I II # Admitted Patients or In&Patients

The needs of in$patients for preventive curativerehabilitative and palliative services as well as other relevantinformation are assessed and prioriti/ed based on his(her health condition at the time of admission in the health carefacility.

Measura$le Elements

?. There is an evidence that nurse screening assessmentfocuses on preventive curative rehabilitative and

palliative services and prioriti/es these according tothe patient’s health condition.

@. There is an evidence that nurse actively participatedin providing relevant information to patient and

family during the admission process which includes but are not limited on the following;

@.?. Proposed plan of care@.@. -)pected outcome of care@.>. -)pected cost of care@.. Sufficient information to ma*e *nowledgeable

decision and

@.=. 5imit or overcome barriers such as languagecultural physical to access and in the deliveryof care

S t andard I V # Intensie and S"eciali)ed Serices

The Nursing Services 'epartment has established entry(or transfer criteria for patients that need intensive andspeciali/ed services to meet special patient needs congruentwith those of the organi/ation.

Measura$le Elements

?. There is an evidence of entry(or transfer criteria for patients that need intensive and speciali/ed servicesto meet special patient needs.

@. It is evident that criteria is physiologic$based anddeveloped by appropriate individuals.

>. It is evident that patients admitted and or transferredto intensive and speciali/ed areas(units meet theestablished criteria and are documented in the

patient record.. There is an evidence that nurses caring for patients

needing intensive and speciali/ed servicesunderwent the related and necessary training.

S t andard V # Continuity of Care

In diverse health care setting the Nursing Services

'epartment has established policies and processes on patientcontinuity of care aligned with those of the organi/ation and

coordinated among other health professionals.



Measura$le Elements

?. The written policies and processes on patient

continuity of care are evident and implemented

throughout all phases of patient care particularly butare not limited in the following services;

?.?. -mergency services to nursing ward admission?.@. Nursing ward services to diagnostic services?.>. Nursing ward services to surgical and

non$ surgical services?.. etween nursing units or clinical departments?.=. Nursing ward services to intensive or

special services?.C. %ut patient care programs

?.<. %ther health care settings@. 'uring all phases of care there is a qualifiedindividual identified as responsible for patient careand documented in the patient record.

>. #ontinuity of care and coordination of services areevident throughout all phases of care.

S t andard V I # Disc(arge* +ut on Pass* Referral and

Follo,&u"

The Nursing Services 'epartment has established policies and processes and guidelines on patient’s dischargeout on pass referral and follow$up congruent with those of the organi/ation.

Measura$le Elements

?. There are written policies procedures and guidelineson patient’s discharge out on pass referral and

follow$up congruent with those of the organi/ation.

@. There are criteria that determine patients readiness to be discharged.

>. There is a process on out on pass patients for adefined period of time.

. There is a referral system of patients for transfer to

other organi/ation.=. The patient’s discharge summary is prepared by

qualified individuals recogni/ed by the organi/ation.C. A copy of patient’s discharge summary is placed in

the patient record and another copy is given to the patient which include but are not limited on thefollowing;C.?. "eason for admissionC.@. Significant physical and other findingsC.>. Significant diagnosis and co$morbiditiesC.. 'iagnostic and therapeutic procedures

performedC.=. 4edications and treatmentsC.C. 4edications to be ta*en at homeC.<. #ondition of patient at the time of dischargeC.D. 6ollow$up instruction in an understandable form

and manner

Activity

'iet

Ne)t medical consultation

:rgent care indicatorsC.E. "eferral for support services to either health care

providers health organi/ations or agency andhealth professionals in the community.

S t andard V I I # -ransfer of Patient

The Nursing Services 'epartment has established policies procedures and guidelines regarding the transfer of

patient within and outside of the organi/ation.



Measura$le Elements

?. There is a written policy procedure and guidelineson transfer of patient within and outside of the

organi/ation.

@. The guidelines and procedures include but are notlimited on the following;@.?. Transfer is based on the patient’s needs for

continuity of care.@.@. Transfer of responsibility to another

health provider or health care setting is evident.@.>. "esponsible health care provider during the

patient’s transfer is identified.@.. 6ormal and informal arrangements are apparent.

@.=. Summary of patient’s clinicalcondition interventions !medical and nursing&

and continuous care rendered are [email protected]. Situation when transfer is not possible is stated.@.<. Patient’s transfer is [email protected]. Safe and quality medical transport services

within and outside of the organi/ation are provided.

V$ Standards on Nursing Documentation

S t andard I # Structural Data

The nurse documents structural data of each patientaccurately and completely based on applicable laws andregulations professional standards and institutionalrequirements.

Measura$le Elements

?. There is an accurate and complete documentationof patients’ structural data in all nursing and

applicable forms which include but are not limitedon the following;

?.?. Patient’s addressograph 8 name agegender civil status

?.@. "egistration number and or Admission

number ?.>. 'ate and time of admission and discharge?.. 4ode of admission(transport(discharge

?..?. Admitted via; ambulatorywheelchair stretcher

?..@. Admitted from; home transferringhospital care facility

?.=. Attending physician and referring physicianif any

?.C. "eligion?.<. 5anguage spo*en

?.D. Advance directive?.E. 2ealth #are Insurance

S t andard I I # Clinical Data

The nurse documents essential clinical data of each patient accurately and completely based on individuali/ednursing care plan from admission to discharge in health carefacility.

Measura$le Elements

?. There is relevant(essential accurate and completenursing documentation of patients’ clinical data in

all appropriate forms from admission to dischargein health care facility which include but are not

limited on the following;?.?. Physical e)amination !head$to$toe&?.@. 2ealth history



?.>. Psychological social spiritual andeconomic evaluation

?.. Actual and potential health problems andneeds

?.=. 'iagnostic and therapeutic interventions

?.C. Pharmacological management?.<. Nursing interventions?.D. 2ealth teachings 8 patient and family?.E. Patients’ response and outcome?.?F. Preferences and idiosyncrasies

AD-INISTRATION 1 -ANAGE-ENT

I$ Standards on Governance and Direction

S t andard I # oernance Structure

The Nursing Services 'epartment has governancestructure designed to delineate lines of relationshipauthority responsibility and accountability and themechanisms for communication and coordination within the

Nursing Services and other services(departments of thehealth care facility.

Measura$le Elements

?. The Nursing Services governance structure is

represented or displayed in an organi/ational chartthat shows functional and positional relationships

and span of control.@. The Nursing Services governance structure is

described in written documents with the approval of proper authority.

>. The Nursing Services governance structure depictsdecentrali/ation or unit$based wherein decision$ma*ing prevails to support and promote patient

safety and quality improvement.. The Nursing Services governance structure and

processes support professional communicationclinical planning and services and policydevelopment.

S t andard I I # oernance Res"onsi$ility and Accounta$ility



The governance responsibility and accountability aredescribed in a written document to guide how they are to be

carried out. Measura$le Elements

?. The governance responsibility and accountability aredescribed in organi/ation’s by$laws +ob descriptionand other similar documents.

@. Those responsible and accountable for governingand managing the Nursing Services 'epartment are

identified by position title and name.>. Those responsible for governance appoint the

Nursing Services Administrator managers professional technical staff and assistive nursing personnel to carry out the functions of the NursingServices 'epartment.

. There is a written document that describes how the performances of the governing entity are appraised by specific criteria.

S t andard I II # Direction&Setting

The Nursing Services 'epartment has an establishedvision mission philosophy core values and qualityob+ectives congruent with that of the institution and the

Nursing profession.

Measura$le Elements

?. Those responsible for the Nursing Services'epartment governance primarily sets its direction

by formulating its vision mission philosophy corevalues and quality ob+ectives congruent with that of the institution and the Nursing profession.

2. The vision mission philosophy and core values arewritten ! specific, measurable, attainable, reliable,

time bound, ethical and recorded & reviewedupdated widely disseminated interpreted andoperationali/ed.

S t andard I V # Strategic % +"erational Plans

The Nursing Services 'epartment has documentedstrategic and operational plans consistent with the hospitalwide quality plan.

Measura$le Elements

?. Those responsible for governance forecast and directthe future and operation of the Nursing Services'epartment in order to achieve its overall goals.

@. There is an e)istence of strategic and operational

plans periodically set and reviewed which contains

goals and ob+ectives action plan(activitiestimeframe resources required and contingencies.

>. Those in the managerial and clinical levels translatethe overall Nursing Services 'epartment’ strategicand management plans into action which include;the management of patient care nursing manpower and unit operation of responsibility areas.

S t andard V # Financial Plan % Resource Allocation

The Nursing Services 'epartment has financial plan and

allocation of resources required to meet its goals and sustainits operation.

Measura$le Elements

?. Those responsible for governance have establishedcurrent financial plans and allocation of resources

based on the needs of the Nursing Services'epartment.



@. The capital and operating budgets are implementedas approved by the authori/ed person(office and

monitored based on responsibility accounting.>. -ach Nursing :nit has an individual budget plan

periodically monitored for variances.

. The medical supplies materials and equipmentrecommended by professional organi/ations andauthoritative sources are obtained and appropriatelyused.

S t andard V I # Policies % Procedures Deelo"ment

The policies and procedures of the Nursing Services

'epartment that reflect Standards of NursingAdministration Nursing Practice on Patient #are are

developed and communicated to serve as operational

guidelines.

Measura$le Elements

?. Those responsible for governance develop andimplement policies and procedures based onestablished Standards of Nursing Administration and

Nursing Service on Patient #are.@. An updated manual of Nursing Services policies and

procedures e)ists and provides clear directive for nursing personnel at different levels on the scope

and limitations of their functions and responsibilitiesto patient care.

S t andard V I I # Et(ico / Moral % 'egal Accounta$ili ties

The Nursing Services 'epartment has an establishedframewor* for ethico$moral and legal management to

support the ethical decision$ma*ing in the clinical areas and

conforms with the applicable statutory laws rules andregulations.

Measura$le Elements

?. Those responsible for governance formulate policiesand procedures to serve as guidelines for thoseconfronted by ethico$moral dilemmas in patient care.

@. Those responsible for governance ensure compliancewith the applicable statutory laws regulations andstandards.

>. The Nursing Services 'epartment has a written#ode of -thical ehavior which observes the rights

and safety of patients and health care providers.

S t andard V II I # Professional % +rgani)ational Inolement

The administrator of the Nursing Services 'epartmentactively participates and collaborates with leaders within theorgani/ation and professional associations for continuousquality improvement of nursing services.

Measura$le Elements

?. Those responsible for Nursing Services 'epartment

governance initiate and maintain formalliaison(lin*age with other departments(sections of the institution and professional associations andagencies pertinent to nursing standards and

practices professional and interprofessionalrelationships and other related endeavors.



II$ Standards on /uman Resource -anagement

S t andard I # Administrator of Nursing Serices

The Nursing Services 'epartment is administered by aqualified nursing administrator pertinent to licensureappropriate education e)perience and demonstrable provenability in nursing practice and administration fullyresponsible and accountable for the operation of the entire

Nursing Services of the organi/ation(institution.

Measura$le Elements

?. There are presence of evidences that the NursingService Administrator is qualified to the position

based on "A E?<> and other criteria set by theorgani/ation(institution such as;?.? 9ualifications of Nursing Service

Administrators;A person occupying supervisory or

managerial positions requiring *nowledge of nursing must;

?.?.?. e a registered nurse in thePhilippines,

?.?.@. 2ave at least two !@& years e)periencein general nursing serviceadministration,

?.?.>. Possess a degree of bachelor of Science in Nursing with a least nine

!E& units in management and

administration courses at the graduatelevel, and

?.?.. e a member of good standing of theaccredited professional organi/ationof nurses.

?.@. A person occupying the position of chief nurseof director of nursing service shall in additionto the foregoing qualifications possess;?.?.?. At least five !=& years of e)perience

in a supervisory or management position in nursing, and

?.?.@. A master’s degree ma+or in nursing.?.>. That for primary hospitals the ma)imum

academic qualifications and e)periences for achief nurse shall be as specified in subsections!?.?.?& !?.?.@.& and !?.?.>& of the above.

?.. That for chief nurses in the public healthagencies, those who have a master’s degree in

public health(community health nursing shall be given priority.

?.=. That for chief nurses in military hospitals priority shall be given to those who havefinished a master’s degree in nursing and thecompletion of the 7eneral Staff #ourse!7S#&.

@. Those responsible for the overall administrationand management of Nursing Services is a member

of the top -)ecutive(4anagement #ommittee who participates in their regular meetings and providesadvice and recommendations in relation to nursing

practice.

S t andard I I2 Staffing Plan



The Nursing Services 'epartment has a staffing planthat identify the number type and desired qualification of nursing services staff which is written reviewed and updatedon an ongoing basis.

Measura$le Elements

?. Those responsible for Nursing Services governancedevelop a staffing plan that identify the number typeand desired qualification !education s*ills ande)perience& of Nursing Services staff reviewed and

updated on an ongoing basis.@. Those responsible for Nursing Services governance

consider the organi/ation’s mission type of services

level and modality of care patients’ mi) staff ands*ills mi) and other factors affecting the pro+ectionof staffing needs.

>. The staffing plan is defined in writing and meets theneeds of the patients(population served and scope of services.

S t andard I II # Recruitment* Selection* Hiring and

A""ointment

The Nursing Services 'epartment has an established

system and processes for recruitment selection hiringappointment and promotion of human resources inaccordance with the statutory laws and regulations and theinstitutional policies and procedures.

Measura$le Elements

?. Those responsible for the Nursing Servicesgovernance actively participate(collaborate in the

development of system and processes for recruitment selection hiring appointment and

promotion of nursing service personnel inaccordance with the statutory laws and regulationsand the institutional policies and procedures.

@. There are legitimate and legitimi/ed processes torecruit select hire and appoint nursing services

personnel and are uniformly implemented.>. Staff recruitment selection hiring and appointment

are based on institutional patients’ needs andapplicant qualification.

S t andard I V # Credentialing

The Nursing Services 'epartment has an effective

process for gathering verifying and evaluating the nursing

staff credentials.

Measura$le Elements

?. Those responsible for Nursing Services governancedevelop an effective process for gathering verifyingand evaluating the nursing staff credentials!licensure education training wor* e)perience& andother pertinent requirements.

@. There is evidence of standardi/ed procedure togather the credentials of all nursing staff.

>. The licensure education training and wor* e)periences of nursing personnel are documentedand updated.

S t andard V # Staff Placement

The Nursing Services 'epartment has defined criteriaand processes to ensure the clinical staff *nowledge and

s*ills are consistent with the patients’ needs.



@. There is evidence that the 0ob 'escription of Nursing Services personnel is reviewed at least once

every > years and revised when necessary.

Measura$le Elements?. Those responsible for Nursing Services governance

develop and define the criteria !core competencies&and processes to match the clinical staff *nowledgeand s*ills with the patients’ needs.

@. There are written core competencies required for every +ob position in the Nursing Servicesorgani/ation to ensure that the staff s*ills areconsistent with the patients’ needs.

>. Staff placement(assignment is based on patientneeds available resources and staff competencies.

S t andard V I # Staff 0o$ Descri"tion

The Nursing Services 'epartment has +ob description for each position classification of Nursing personnel whichspecifies duties and responsibilities based on establishedstandards of performance.

Measura$le Elements

?. There is a written 0ob 'escription for each position

classification of Nursing Services personnel whichspecifies;

?.?. 'uties and responsibilities?.@. Accountability?.>. 6unctional relationship?.. 9ualification and e)perience required

S t andard V I I # Staff Deelo"ment

The Nursing Services 'epartment has an establishedstaff development program for all nursing personnel toencourage and promote continuing personal and professionalgrowth and development.

Measura$le Elements

?. Those responsible for Nursing Services governance

design and implement staff development programsfor nursing personnel at all levels based on trainingneeds analyses.

@. There is evidence of staff development programs for all nursing personnel throughout the year whichinclude;a. %rientation program for newly hired and

promoted staff to the organi/ationdepartment(unit to which they are assigned as

well as their specific +ob responsibilities. b. Safety program to protect the patient staff and

property.c. #ontinuing education training and opportunities

for professional advancement of staff member toenhance their *nowledge and s*ills.

d. #areer counseling and career advancement(ladder.

>. "esources are available to implement the staff development program such as;



>.?. Space and facilities>.@. -ducational resources>.>. #linical and clerical staff >.. Audiovisual equipment>.=. "esource spea*ers

. Policies and procedures on continuing educationstaff attendance to staff development programs areevident.

=. "ecords of staff development program aremaintained which include;=.?. Title of the program=.@. %b+ectives of the program

=.>. Program design and content=.. -valuation of the attendees

=.=. -ffectiveness of the program=.C. 5ist of attendees(participants

III$ Standards on Faci!it. -anagement 1 Environment

Safet.

S t andard I2 Facility Planning

6or efficient and effective delivery of nursing care andservices the Nursing Services 'epartment provides a safefunctional and supportive facility to patients and their

families staff and visitors aligned with that of theorgani/ation’s master plan.

Measura$le Elements

?. Those responsible for governance comply with

relevant laws regulations and other requirementsthat are applicable.

@. Those responsible for governance actively participate in space planning as well as medicalequipment and supplies procurement.

>. Those responsible for governance plan and budgetfor upgrading or replacing *ey components based on

facility inspection findings.

S t andard I I2 Enironmental Safety

The Nursing Services 'epartment actively participatesin the planning implementation and evaluation of hospital 8 wide programs to provide a safe and secure physicalenvironment.

Measura$le Elements

?. There is a written and up$to$date planimplementation and evaluation of

programs(activities to manage the ris*s within theenvironment which includes but is not limited on thefollowing;?.?. Safety and Security

There is an e)isting provision for theidentification of patient and their familiesvisitors staff and others.

4onitoring mechanism of all ris* areas isin place and *ept secure to patient from

unauthori/ed access or use tamperingdestruction or loss. !e.g. 4edication"oom&

?.@. 2a/ardous 4aterials and 1aste

There is a current list of ha/ardousmaterials and waste to safely control them!e.g. chemotherapeutic agents chemicalsradio$active materials and waste



ha/ardous gases and vapors infectiouswaste&.

There is an e)isting written processes onhanding labeling storage use inventoryand disposal of ha/ardous materials and

waste.'ocumentation and reporting system arein place for investigation of spillse)posures and other accidents related toha/ardous materials and wastes.

?.>. 4edical -quipment

There is an updated policy and processeson medical equipment procurement

inventory regular inspection preventivemaintenance and recall system.

4onitoring of equipment functionality andutili/ation is in place for purposes of

planning and improvement.

?.. :tilities

Potable water electrical power andmedical gases are available @ hours aday seven !<& days a wee*.

A written emergency processes is in placein the event of water interruption or contamination electrical failure or interruption and medical gasesunavailability.

4onitoring of utilities is evident for purposes of planning and improvement.

?.=. -mergencies

An emergency management plan and processes are evident to li*ely community(

institutional emergencies epidemics anddisasters.

?.C. 6ire Safety

There is an evidence that fire safety planand program of theorgani/ation(institution is implemented ina continuous and comprehensive manner to all patient care and staff wor* areas.

?.<. Infection #ontrol

There is evidence that policies procedures

and guidelines on infection control areimplemented.

There are infection surveillance prevention and control programs toidentify and reduce the ris*s of acquiringand transmitting infections among patientsand nursing staff.

There is evidence that the nursing staff is provided with education on infectioncontrol practices.

S t andard I II2 Staff Education

The Nursing Services 'epartment ensures education and

training of staff to effectively carry out their roles in creatinga safe and sound patient and staff environment.

Measura$le Elements



?. There is an evidence of staff education and trainingon facility management and environmental safety

programs.@. There is an evidence that the staff can describe and

demonstrate their role in the aforementioned safety

programs.>. There is an evidence of staff training to operate

medical equipment appropriate to their +obdescription.

VI$ Standards on Communication -anagement

S t andard I2 Communication of Information

The Nursing Services 'epartment has efficient and

effective system of communication with the community to

patients and their families nursing personnel and other health professionals throughout the organi/ation.

Measura$le Elements

?. There is efficient and effective system of communication that e)ist which include but are notlimited on the following;?.?. #ommunity

Patient(nursing care services

2ealth programs

Process to access care

?.@. Patients and 6amilies

Patient health condition

#are provided to patient

Patient’s response to care

Patient(nursing care services available

Alternative sources of care and services

Process to access care

-ducational materials and methods in anunderstandable format and language

?.>. Nursing Personnel

Nursing endorsement in between wor*

shifts Nursing documentation

"eferral

Nursing Service Philosophy 3ision4ission #ore 3alues

Policies Procedures 7uidelinesStandards

4emorandum #ircular 'irectivesActivities

?.. %ther 2ealth Professionals !clinical and non$

clinical staff&Patient care and response to care !referral&

Patient clinical data !diagnostic

e)aminations and therapeutic procedures&

#ircular

S t andard I I2 Patient Clinical Record

The Nursing Services 'epartment has established policies procedures and guidelines on patient clinical record.

Measura$le Elements

?. There are written policies procedures andguidelines on patient clinical record which include

but are not limited on the following;?.?. #linical record for every patient assessed

or treated in$patient or out$patient?.@. #onfidentiality of record?.>. Security of record



Protection from loss and destruction andunauthori/ed access and use

?.. 'ata Integrity

Protection from tampering?.=. :se and monitoring of standardi/ed

abbreviations symbols procedure codes anddefinitions

?.C. "etention period of records !as prescribed by law and institutional policy&

S t andard I II2 Administratie Record


policies or protocol in *eeping and maintaining itsadministrative record and defining the requirements for

developing and maintaining policies and procedures.

Measura$le Elements

?. There is a written policy or protocol in *eeping andmaintaining Nursing Services 'epartmentadministrative records which include but are notlimited on the following;?.?. %rgani/ation and Nursing Services 'epartment

Policies Procedures 7uidelines?.@. Standards?.>. 4aster Staffing Plan

?.. Staffing Pattern?.=. #ensus of Patients and 'iseases?.C. ed #apacity and %ccupancy "ate?.<. udget Plan?.D. Staff 'evelopment Programs?.E. #ommittees Nursing and the %rgani/ation?.?F.4inutes of 4eeting Nursing Services

'epartment

?.??.9uality Improvement Program and other Pro+ects

[email protected] of the %rgani/ation

9uality System

Infection #ontrol

-mergency Preparedness

-mployees’ 4anual

%thers@. There is written policy or protocol in developing and

maintaining policies and procedure which include but are not limited on the following;@.?. "eview and approval of all policies and

procedures before implementation@.@. Process and frequency of review and continued

approval of policies and procedures@.>. #ontrol that only current policy and procedures

are implemented@.. Identification of charges in policy and

procedures@.=. "etention of obsolete policies and [email protected]. "eferences originating outside the organi/ation@.<. Trac*ing of policy and procedures in circulation

!e.g. title date of issue authori/ed person&

V$ Standards on 0ua!it. Im"rovement

S t andard I2 'eaders(i" and Staff Education

The Nursing Services 'epartment has continuous qualityimprovement on patient and staff safety programs throughmonitoring and analy/ing variation of data and undesirabletrends of events.

Measura$le Elements



?. Those responsible for governing and managing the Nursing Service 'epartment lead or actively participate in planning monitoring analy/ing andimplementing quality improvement and patient andstaff safety programs congruent with the

organi/ational needs.@. There is an evidence that information on quality

improvement and patient and staff safety programsare communicated to staff on a regular basis througheffective channels inclusive of progress on

compliance.>. There is a training program for staff consistent with

their role in quality improvement and patient safety program.

. There is a qualified trainer who provides the trainingand staff participation as part of their regular wor*

assignment.=. There is an established reporting system on the

quality and safety programs to governance.C. Those in governance support and ta*e action on

recommendation for quality improvement and patient and staff safety programs based on the resultof root cause analysis.

S t andard I I2 !uality Programs

The Nursing Services 'epartment has priority quality

programs to reduce high volume high ris* and problem$ prone processes.

Measura$le Elements

?. There is written plan or policy or document of a welldesigned new processes or modified e)isting

processes consistent with current practiceguidelines clinical standards scientific literature

and other relevant evidence 8 based information.!e.g. 4edication safety clinical pathway&

@. There is an e)isting plan and program to reduce theris* of community(hospital acquired infectious for

patients and health care associated infections for

staff.>. There is an evidence that the qualityimprovement(processes and safety programs areapproved by governance implemented andmonitored for consistent use and effectiveness.

S t andard I II2 !uality Monitoring* Analysis %

Im"lementation

The Nursing Services 'epartment has established *eyindicators to monitor the clinical and managerial structure

processes and results and data are aggregated analy/ed andtransformed to useful information.

Measura$le Elements

?. There is a clinical monitoring that e)ists but is not

limited on the following;?.?. #linical research?.@. Nursing documentation?.>. 4edication error ?.. Intravenous fluids?.=. lood and blood products

?.C. Total parenteral nutrition?.<. Surgical safety !sterili/ation(disinfection&?.D. Infection control surveillance reporting

!needle stic* in+ury hand hygiene and barrier technique body fluids and wastesegregation(disposal&

?.E. Prevention and control measures aligned withInternational Patient Safety 7oals. !IsolationProcedure&



@. There is a managerial monitoring that e)ists but isnot limited on the following;@.?. Patient demographics and clinical diagnoses@.@. Patient and family e)pectations and

complaints if any

@.>. Availability of drugs and medical suppliesessential to most patient needs !e.g. -mergencyBart contents&

@.. 6inancial budget@.=. 4anpower utili/ation

@.C. Staff e)pectations and satisfaction@.<. Incident reports and sentinel [email protected]. "eports as required by law and regulation and

those in governance>. There is an evidence data analysis and actions ta*en.. There is an evidence that actions for improvement

are appropriate to the care scope and severity of the

problems.=. There is an evidence that the actions for

improvement or changes are planned tested andimplemented.

C. There is a written available data to demonstrate thatthe improvements are effective and sustained.

G,OSSAR3

Adverse Event 8 is an unanticipated or potentiallydangerous occurrence in health care organi/ation.

C!inica! ath4a.s 8 is an agreed$upon treatment regimethat includes elements of care.

Communication -anagement 8 is the creation usesharing and disposal of data or information for effective and

efficient operation of organi/ation activities. It includes therole of management to produce and control the use of data

and information in wor* activities information resourcesmanagement information technology and information

services.

Continuit. of Care 8 is the matching of an individual’songoing needs with the appropriate care setting, level of medical psychological or nursing care, or spiritual andsocial care or service. This applies within an organi/ation or across multiple organi/ations.

Credentia!ing 8 is the process of obtaining verifying andassessing the qualifications of a health care practitioner li*ethe nursing personnel. The process determines if anindividual can provide patient care services in or for a healthcare organi/ation.

Discharge Summar. 8 is a section of patient record thatsummari/es the reasons for admittance the significantfindings the procedures performed the treatment renderedthe patient’s condition on discharge and other specific



instructions given to the patient or family !for e)amplefollow 8up medications&.End5of5,ife Care 6 is the provision of care to the patientwhose disease condition is not responsive to curativetreatment and his(her life e)pectancy is estimated to be

within days or months.

Governance 8 refers to the individual!s& group or agencythat have ultimate authority and responsibility for establishing policy maintaining quality of care and

providing for organi/ation management and planning. %ther names for this group include GboardH Gboard of trusteesH

board of governorsH Gboard of commissionersH andGgoverning body.H

/ea!th Care Organi7ation 8 is a generic term used to

describe many types of organi/ations that provide healthcare services. This includes ambulatory care centers behavioral(mental health institutions home care

organi/ations hospitals laboratories and long termorgani/ations. It is also *nown as a Ghealth care institution.H

/ea!th Care rofessiona! 8 is any person who has

completed a course of study and is s*illed in a field of health. This includes a physician dentist nurse or allied

health professionals. 2ealth care professionals are oftenlicensed by a government agency or certified by a

professional organi/ation.

Indicator 8 is a measure of the performance of functionssystems or process over time.

Informed Consent 6 is an agreement or permissionaccompanied by full information on the nature ris*s and

alternatives of a medical procedure or treatment before the

physician or other health care professional begins the procedure or treatment.

In5Service Education 6 is an organi/ed education usually

provided in the wor*place designed to enhance the s*ills of

staff members or teach them new s*ills relevant to their +obsand disciplines.

a!!iative Services 6 are treatments and support servicesintended to alleviate pain and suffering rather than to cureillness.

atient Record8C!inica! Record 6 is a written account of avariety of patient health information such as assessmentfindings treatment details progress notes and dischargesummary. This record is created by nurses physicians and

other health care professionals involved in the care of patients.

!an of Care 6 is a plan that identifies the patient’s careneeds lists the strategy to meet those needs documentstreatment goals and ob+ectives outlines the criteria for ending intervention and documents the individual’s progressin meeting specified goals and ob+ectives. It is based on datagathered during patient assessment. The format of the planin some organi/ations may be guided by specific policiesand procedures protocols practice guidelines clinical paths

or a combination of these. The plan of care may include prevention care treatment habilitation and rehabilitation.

0ua!ified Individua! 6 is an individual or staff member whocan participate in one or all of the organi/ation’s care

activities or services. 9ualification is determined by thefollowing; education training e)perience competence

applicable licensure law or regulation registration or certification.



0ua!it. of Care 8 is the degree to which health services for individuals and populations increase the li*elihood of desired health outcomes and are consistent with current

professional *nowledge.

Safet. 6 is the degree to which the ris* of an interventionand ris* in the care environment are reduced for a patientand other persons including health care providers.

Standard 8 is a statement that defines the performancee)pectations structures or process that must be in place for

an organi/ation to provide safe and high$quality caretreatment and service.

Standard of Nursing ractice 6 is an authoritative

statements that describe the responsibilities for whichnursing practitioners are accountable.

Outcome Standards 8 'escribes the basis level of care the patient can e)pect to receive.

REFERENCES

Association of Nursing Service Administrators of thePhilippines Inc. !@FF?& Standards of Nursing Services

Association of Nursing Service Administrators of thePhilippines Inc. and Philippine Nurses Association Inc.!?EEE&. Standards of Safe Nursing Practice

#ommittee on the "evision of the 2ospital Nursing ServiceAdministrative 4anual !?EEF&. The Administration of 2ospital Nursing Services in Philippine 'epartment of

2ealth ?st

-dition

0oint #ommission International !@FFD&. Accreditation Standardsfor 2ospitals >

rd-dition Printed in :SA =>@?

0oint #ommission International !@FF&. #redentialing -ditionPrinted in :SA =>@?

0oint #ommission International !@FF&. 2uman "esources for 2ospitals -dition Printed in :SA =>@?

Noe 2ollenbac* 7erhart 1right !@FF&. 6undamental of 2uman "esource 4anagement 4c7raw$2ill #o. Inc. New

or*

"epublic Act E?<> or The Philippine Nursing Act of ?EE?"epublic of the Philippines 4etro 4anila

"obbins S. #oulter 4 !@FF&. 4anagement <th

-ditionPearson -ducation South Asia PT- 5T'.



"owland 2 J "owland !?EDF&. Nursing Administration2andboo* Aspen Publication

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

5eadership <th

-dition

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

-dition 5ippincott 1illiams J 1il*ins

Standards of Nursing Services ANSAP

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