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The development was actively participated by the Board of Nursing (PR- BON) and the Unsnaps Board of Directors and validated by the Chief Nurses/Nursing Directors who are also members of NSAP. The Initial draft was eventually reviewed and discussed by opinion leaders in focus group of experts. The final blueprint was presented to public hearing attended by key stakeholders around the country. This edition contains a complete set of standards presented in two major components namely; the Clinical and Administration management.
Each component has five standards, criteria and measurable elements necessary to help organizations educate the staff. This edition is also a cross-reference to corresponding requirements set forth In the Philippines by NSAP and the international accrediting body like Joint Commission International OIC). We view that standards are continuously a work In progress. Hence, we welcome any comments and suggestions for Improvement. V. TABLE OF CONTENTS Introduction Clinical Services l. Standards on Assessment of Care Standard l. Assessment Process Standard II. II.
Assessment Scope and Content Standards on Care of Patient Standard I. Care Process Standard II. Care Plan Standard Ill. Implementation of Care Standard IV. Evaluation of Care Standard V. Pain Management Standard VI. Medication Management Standard VII. End-of-Life Care Standard VIII. Patient and Family Rights Standards on Patient and Family Education Standard l. Education Assessment Standard II. Education Plan and Programs Standards on Access and Continuity of Care Standard l. Access to Care Standard II. Intensive and Specialized Services Standard V. Standard VI. Standard VI’.
Continuity of Care Discharge, Out on Pass, Referral and Follow-up Transfer of Patient Standards on Nursing Documentation Standard I. Structural Data Standard II. Clinical Data Administration and Management l. Standards on Governance and Direction Standard l. Governance Structure Standard II. Governance Responsibility and Accountability Standard Ill. Direction-setting Standard ‘V. Strategic and Operational Plans Standard V. Financial Plan and Resource Allocation Standard VI. Policies and Procedures Development Standard VI’. Ethics – Moral and Legal Accountabilities Standard VIII.
Professional and Organizational Involvement Standards on Human Resource Management Standard l. Administrator of Nursing Services Standard II. Staffing Plan Standard Ill. Recruitment, Selection, Hiring and Appointment Standard ‘V. Credentialing Standard V. Staff Placement Standard VI. Staff Job Description Standard V. Staff Development Standards on Facility Management and Environment Safety Standard l. Facility Planning Standard II. Environmental Safety Standard Ill. Staff Education Standards on Communication Management Standard l. Communication of Information Standard II. Patient Clinical Record Standard Ill.
Administrative Record Standards on Quality Improvement Standard l. Leadership and Staff Education Standard II. Quality Programs Standard Ill. Quality Monitoring, Analysis and Implementation INTRODUCTION This manual is designed to assist health organizations or hospitals with the significant standards necessary to deliver quality nursing service to our clients. To achieve this, this designed manual has two components; Clinical and Administration and Management. The first part is Clinical Services. This component focuses on defining what the standards are in the clinical setting.
Utilizing nursing process – there are five identified standards to wit: Standards on Assessment of Care. Classified under are two criteria which include the re seven (7) identified criteria that identify care process, care plan, implementation of care and evaluation of care rendered. Included also is the medication management and the family rights. Standards on Patient and Family Education has two criteria in which the nurse’s independent role in providing health education is hereby identified. Standards on Access and Continuity of Care.
There are seven (7) criteria that guide the nurses regarding the importance of access to care. These standards identify the need to establish policies and procedures from admission to discharge and referral follow up. Deed in the delivery of nursing services and training of personnel to effectively carry out their respective roles. Standards on Nursing Documentation. There are two identified criteria under this component, which include documentation of significant data both structure, and clinical based on applicable laws and regulations, professional standards and institutional requirements.
Standards on Communication Management. Three (3) criteria are identified focusing on the patient’s record, administration record and communication of information. It also enables the chief nurses/administrator to develop a specific hospital system which is efficient and effective. Standards on Quality Improvement. This standard has three (3) criteria which address the need to institutionalize continuous quality and performance improvement. The second part is the Administration and Management.
This concerns managing the nursing services in the hospital. There are five (5) standards identified: Standards on Governance and Direction. There are seven (7) criteria included. This chapter recommends the need for organizational structure which will delineate responsibility, accountability and authority of nursing administration. These focus also on planning, direction, organization and controlling functions of the nursing service administration and their relationship with other services. Standards on Human Resource Management.
This part contains five (5) criteria which help the nursing administrators in placing the right person to do the right Job through identification of the Job requirements and qualifications. It also includes staffing modalities depending on the type of services. Standards on Facility Management and Environmental Safety. This standard contains three (3) criteria and covers environmental safety Each standard and criteria has identified measurable elements intended to provide clarity to the standards and to help organizations develop their own policies and procedures according to the standards.
CLINICAL SERVICES l. Standards on Assessment of Care Standard l: Assessment Process The nurse identifies the health care needs of each patient based on an established assessment process and within the prescribed timeshare. Measurable Elements 1. There is an evidence of initial and completion of nursing assessment on the health care needs of each patient within the: 1. 1 . 1st 24 hours of admission as an in-patient or earlier as indicated by the patient’s condition or institutional policy. 1 . 2. 1st 2 hours of consultation as an outpatient or earlier as indicated by patient’s condition or institutional policy. . There is an evidence of patient’s reassessment throughout the care process to determine response to intervention at interval appropriate to patient’s condition, plan of care, individual needs or according to institutional policies and procedures (e. G. Pain is assessed every 4 hours and as necessary as part of the vital signs monitoring). 3. Those responsible for direct nursing care collaborate with medical and allied staff o analyze and integrate the patient’s assessment data and information. 4. Those responsible for direct nursing care prioritize patients’ needs based on assessment results. . Those responsible for direct patient care inform the patient and family of the assessment outcome and the planned care and treatment regimen and encourage participation of the latter in the decommissioning about the priority needs to be met. Standard II: Assessment Scope & Content The scope and content of nursing assessment are well defined in an institutional policy wherein those disciplines are identified. Measurable Elements 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: 1. 1 .
Psychological ; Knowledge level ; Language spoken ; Barriers to learning 1. 2. Physical ; Neurological assessment ; Cardiovascular assessment ; Respiratory assessment ; Gastrointestinal assessment ; Genitourinary assessment ; Musculoskeletal assessment ; Intermediary assessment ; Sensory assessment 1. 3. Social ; Cultural concerns 1. 4. Spiritual ; Religion 1. 5. Economic factor ; Financial barrier 1. 6. Health history ; Developmental history (for theatrics) ; Family history ; Medications taken ; Allergies 1. 7. Vital signs 1. 8. Pain assessment 1. 9. Nutritional status, needs and risks 1. 0. Preference and idiosyncrasies 1. 11 . Discharge plan ; Place: home, extended, skilled care facility ; Individual who will accompany the patient home (name, address, telephone number, relationship) 2. There is an established screening criteria according to patients’ functional capacity and needs like: 2. 1 . Nutritional – Metabolic Pattern 2. 2. Elimination Pattern 2. 3. Activity – Exercise Pattern 2. 4. Sleep – Rest Pattern 2. 5. Sexuality – Reproductive Pattern 2. . Sensory – Perceptual Pattern 2. 7. Cognitive Pattern 2. 8. Role – Relationship Pattern 2. 9. Self – Concept Pattern 2. 10.
Coping – Stress Tolerance Pattern 2. 11 . Value – Belief Pattern 3. Other pertinent data are collected using the appropriate assessment, technique and instruments. 4. The nursing assessment findings are documented in the individual patient’s record and readily available to those responsible for his/her care. 5. Discharge plan is evident in the initial assessment of the nurse particularly to those patients when discharge planning is critical as evidenced by the following: 5. . Age 5. 2. Lack of mobility 5. 3. Continuing medical and nursing needs 5. 4. Assistance with activities of daily living 5. 5.
Referral for continuity of care as necessary II. Standards on Care of Patient Standard l: Care Process The Nursing Services Department has an established 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. 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. 1. 2. 1. 3. Care of emergency patients (including use of resuscitation equipment) Care of patient on life support (e. . Ventilators equipment) Care of patient on dialysis (hemophilia’s, peritoneal dialysis) Care of patients at risk: Neonates ; Critically-ill Children ; Mentally disadvantaged ; Under anesthesia Elderly Disabled Care of comatose patient Care of patient with communicable diseases Care of patient in restraint Care of patient on chemotherapy Care of immune – suppressed patients blood and blood components Care of patient receiving medications with narrow argil of safety Care of preoperative patient Care of patient with intravenous therapy 1 .
There is a written care plan on every patient cared of 2. By the nurse based on patient’s initial assessment data within the 1st 24 hours of assessment or earlier. 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 The care plan reflects the related and relevant identified needs and problems of each patient cared for. The care plan ensures that priorities of care are established.
The care plan is updated as appropriate based on the reassessment made. The care plan is documented in the individual patient’s record to promote continuity of care. 1. 4. 1. 5. 1. 6. 1. 7. 1. 8. 1. 9. 1. 10. 1. 11. 1. 12. 1. 13. 1. 14. 1. 15. Standard Ill: Implementation of Care The nurse caring for patients implements nursing intervention and carries out medical orders utilizing critical thinking and sound clinical Judgment for the promotion of health, prevention of illness, alleviation of suffering and restoration of health.
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: Standard II: Care Plan The nurse caring for patients develops and updates an individualized written care plan in the patient’s record within the prescribed time frame.
Measurable Elements 1. 1 . Scope of Nursing Practice as provided by law and all relevant legislations (e. G. The Philippine Nursing Act of 2002 or Republic Act 9173) The nurse caring for patients systematically and continuously evaluates the patient’s regress based on the effectiveness of nursing intervention rendered and medical management provided. 1. 2.
Standard of Care: ; Acute and Critical Care Nursing Practice ; Chronic Care Nursing Practice ; Cardiovascular Nursing Practice ; Preoperative Nursing Practice ; Maternal and Child Nursing Practice ; Psychiatric Nursing Practice ; Emergency Nursing Practice ; Renal Nursing Practice ; Pediatric Nursing Practice ; Oncology Nursing Standard on Intravenous Therapy ; Infection Control Nursing Practice 1. 3. Evidence – based practice 1. 4. Ten (10) Golden Rules in Drug Administration 1. 5. Code f Ethics for Nurses 1. 6. Patient Bill of Rights 2.
It is evident that implementation of interventions/care is delivered in a safely manner that minimizes complications and life-threatening situations. Standard lb. Evaluation of Care Measurable Elements 1 . Systematic and continuous evaluation of patient’s 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 patient’s responses to interventions are documented. The revision in care plan if any is reflected in the patient record. Standard V. Pain Management The Nursing Services Department has established pain management guidelines for nurses to appropriately assess, monitor, evaluate and manage patients in pain. 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. 4.
Processes to communicate with and evaluate patients and families about pain are evident. Standard VI: Medication Management The Nursing Services Department has established policies, procedures and guidelines on medication management for symptomatic, curative, preventive, and palliative treatment of patients’ diseases and for safe nursing practice. 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 physician’s medication order 1. 2. Transcribing and ordering 1. 3. Endorsing (especially high valuable drugs) 1. 4.
Preparing 1. 5. Labeling 1. 6. Administering (10 Golden Rules in Drug Administration) 1. 7. Documenting 1. 8. Monitoring and Storage 1. 9. Emergency Drugs 1. 10. Regulated Drugs 1. 11 . Medication Recall System (Expired or Outdated Drugs) 1. 12. Reporting on ; Medication effects and adverse effects ; Medication error and near-miss Standard VI’: End-of-Life Care The nurse provides an end-of-life care to facilitate a dignified and peaceful closure of life for patients through physiological, psychological, social and spiritual care taking into consideration the cultural verities in beliefs and customs and optimize caring environment.
Measurable Elements 1 . Respect for patient’s values, religion and cultural preferences and practices is evident. 1. 1 . Pastoral services are provided based on the spiritual beliefs of the patient and family. 1. 2. The patient’s right of self-determination and choices are respected and accommodated. 1. 3. Advance directives Do Not Resuscitate, Waiver, Living will if any, are respected. 1. 4. Patient and family choices to donate organs and other tissue are supported through provision of relevant information. In accordance to statutory laws, rules and regulations. . Assessment, appropriate intervention to alleviate the patient’s pain and discomfort according to wishes of and evaluation, are monitored and recorded. 2. 2. Personal hygiene is rendered based on patient’s need. 2. 3. Nutritional assessment and risks are identified and nutritional needs are provided such as feeding and hydration. 2. 4. Interventions address patient and family psychosocial, emotional, spiritual and cultural concerns. 3. A place is designated for the patient’s family to stay. 4. The patient and family are involved in care management and decision.
Standard VIII: Patient and Family Rights The Nursing Services Department has established policies, processes and guidelines that respect and support patient and family rights. Measurable Elements 1 . There are written policies, processes and guidelines that respect and support patient and family rights which include but are not limited on the following: 1. 1 . Prerogative to determine what information regarding health condition and care is provided to family and under what circumstances. 1. 2. Respect for patient’s personal values and beliefs 1. 3. Respect the confidentiality of patient health information 1. 4.
Respect for patient’s need for privacy (e. G. During treatment, procedure, physical examination, clinical interview, transport) 1. 5. Protection of patient’s possessions from theft or loss 1. 6. Protection of patient from physical assault (e. G. Vulnerable patients are infants, children and elderly) 1. 7. Support patient and family rights by participating in the care decision and care process through information of the following: ; Medical condition and confirmed diagnosis and the informant ; Planned care, treatment, outcome of care, unanticipated outcome and participation in care decision according to wishes ;
Informed consent ; Refusal or discontinuance of treatment ; Withholding life- sustaining treatments ; Assessment and management of pain ; Compassionate care at the end-of-life ; Process on complaints and differences of opinion about patient care ; Participation in clinical research ; Organ donation and other tissues ; Disclosure of information 2. There is evidence that nurses are knowledgeable and supportive of patient and family rights. Ill.
Standards on Patient and Family Education Standard l: Education Assessment The nurse assesses the educational needs of each tenant and family and documents these in his/her patient record. Measurable Elements 1 . 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 . Patient’s and family beliefs and values 1. 2. Patient’s and family literacy 1. 3. Patient’s and family educational level 1. 4. Patient’s and family language 1. 5.
Patient’s and family motivations and emotional barriers 1. 6. Patient’s physical and cognitive limitation 1. 7. Patient’s willingness to receive information Standard II: Education Plan and Programs The Nursing Services Department has established educational plans and programs that support patient and family participation in care decisions and care processes with the primary objective of rehabilitating the patient back to his/her functional level and optimal health. Measurable Elements 1 . The educational plan and programs for 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 4. . Treatment and diagnostic procedures ‘V. 5. It is evident that standardized materials and processes in educating patient and family on the aforementioned topics (4. 1 to 4. 5) are available. 6. There is an evidence that nurses who provide education have the subject knowledge, adequate time and immunization skills to do so. Standards on Access and Continuity of Care Standard l: Access to Care In diverse health care setting, the Nursing Services Department has established policies and processes on patient access to care aligned with the organization.
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 training or screening is initiated at the point of 1st contact with the patient 1. 3. Criteria for admitting patient or registering out patient 1. 4. Process for admitting patient or registering out patient 1. 5. Holding area for patient on observation 1. 6.
Managing patient when bed or space or facilities is not available Standard II: Emergency Patients The patients with emergency or immediate needs/care are given priority for assessment and treatment by the nurse. Measurable Elements 1 . There is an evidence that patients with immediate needs/ care are assessed, prioritize 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.
Standard Ill: Admitted Patients or In-patients The needs of in-patients for preventive, curative, rehabilitative and palliative services as well as other relevant information are assessed and prioritize based on his/her health condition at the time of admission in the health care facility. Measurable Elements 1. There is an evidence that nurse screening assessment focuses on preventive, curative, rehabilitative and palliative services and prioritize these according to the patient’s health condition. 2.
There is an evidence that nurse actively participated in providing relevant information to patient and family during the admission process which includes but 2. 1 . Proposed plan of care 2. 2. Expected outcome of care 2. 3. Expected cost of care 2. 4. Sufficient information to make knowledgeable decision and 2. 5. Limit or of care Standard lb. Intensive and Specialized Services The Nursing Services Department has established entry/ or transfer criteria for patients that need intensive and specialized services to meet special patient needs congruent with those of the organization.
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 appropriate individuals. 3. It is evident that patients admitted and or transferred to intensive and specialized areas/units meet the established criteria and are documented in the patient record. 4. There is an evidence that nurses caring for patients needing intensive and specialized services underwent the related and necessary training.
Standard V: Continuity of Care In diverse health care setting, the Nursing Services Department has established policies and processes on patient continuity of care aligned with those of the organization and coordinated among other health professionals. 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 admission 1. 2.
Nursing ward services to diagnostic services 1. 3. Nursing ward services to surgical and nonsensical services 1. 4. Between nursing units or clinical departments 1. 5. Nursing ward services to intensive or special services 1. 6. Out patient care programs 1. 7. Other health care settings 2. During all phases of care, there is a qualified individual, identified as responsible for patient care and documented in the patient record. 3. Continuity of care and coordination of services are evident throughout all phases of care.
Standard VI: Discharge, Out on Pass, Referral and Follow-up The Nursing Services Department has established policies and processes and guidelines on patient’s discharge, out on pass, referral and follow- up congruent with those of the organization. Measurable Elements 1. There are Ritter policies, procedures and guidelines on patient’s 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. . There is a process on out on pass patients for a defined period of time. 4. There is a referral system of patients for transfer to other organization. 5. The patient’s discharge summary is prepared by qualified individuals recognized by the organization. 6. 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 the following: 6. . Reason for admission 6. 2. Significant physical and other findings.