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Association of Nursing Service Administrators

of the Philippines, Inc.

Committee on Nursing Practice

2008 Edition

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.
This publication is designed to provide nursing
administration a guide reference in managing nursing services.
It also reflects the ANSAP’s deep commitment in improving the
• Introduction
quality of patient care and management of nursing services in the • Clinical Services
I. Standards on Assessment of Care
The development was actively participated by the Board Standard I. Assessment Process
of Nursing (PRC-BON) and the ANSAP’s Board of Directors
Standard II. Assessment Scope and Content
and validated by the Chief Nurses/Nursing Directors who are
also members of ANSAP. The initial draft was eventually II. Standards on Care of Patient
reviewed and discussed by opinion leaders in focus group of Standard I. Care Process
experts. The final blueprint was presented to public hearing Standard II. Care Plan
Standard III. Implementation of Care
attended by key stakeholders around the country. Standard IV. Evaluation of Care
Standard V. Pain Management
This edition contains a complete set of standards Standard VI. Medication Management
presented in two major components namely; the Clinical and Standard VII. End-of-Life Care
Standard VIII. Patient and Family Rights
Administration management. Each component has five
standards, criteria and measurable elements necessary to help III. Standards on Patient and Family Education
organizations educate the staff. Standard I. Education Assessment
Standard II. Education Plan and Programs
This edition is also a cross-reference to corresponding
IV. Standards on Access and Continuity of Care
requirements set forth in the Philippines by ANSAP and the Standard I. Access to Care
international accrediting body like Joint Commission Standard II. Emergency Patients
International (JCI). Standard III. Admitted Patients or In-Patients
Standard IV. Intensive and Specialized Services
We view that standards are continuously a work in
Standard V. Continuity of Care
progress. Hence, we welcome any comments and suggestions Standard VI. Discharge, Out on Pass, Referral and Follow-up
for improvement. Standard VII. Transfer of Patient

V. Standards on Nursing Documentation

Standard I. Structural Data
Standard II. Clinical Data
• Administration and Management
I. Standards on Governance and Direction
Standard I. Governance Structure This manual is designed to assist health organizations or
Standard II. Governance Responsibility and Accountability
hospitals with the significant standards necessary to deliver
Standard III. Direction-Setting
Standard IV. Strategic and Operational Plans quality nursing service to our clients. To achieve this, this
Standard V. Financial Plan and Resource Allocation
designed manual has two components; Clinical and
Standard VI. Policies and Procedures Development Administration and Management.
Standard VII. Ethico – Moral and Legal Accountabilities
Standard VIII. Professional and Organizational Involvement The first part is Clinical Services. This component focuses
on defining what the standards are in the clinical setting.
II. Standards on Human Resource Management Utilizing nursing process – there are five identified standards to
Standard I. Administrator of Nursing Services wit:
Standard II. Staffing Plan
Standard III. Recruitments, Selection, Hiring and Appointment
Standard IV. Credentialing
I. Standards on Assessment of Care. Classified
Standard V. Staff Placement under are two criteria which include the process and
Standard VI. Staff Job Description scope and content of assessment.
Standard V. Staff Development
II. Standards on Care of Patient. There are seven (7)
III. Standards on Facility Management and Environment identified criteria that identify care process, care
Safety plan, implementation of care and evaluation of care
Standard I. Facility Planning rendered. Included also is the medication
Standard II. Environmental Safety management and the family rights.
Standard III. Staff Education

IV. Standards on Communication Management III. Standards on Patient and Family Education has
Standard I. Communication of Information two criteria in which the nurse’s independent role in
Standard II. Patient Clinical Record providing health education is hereby identified.
Standard III. Administrative Record
IV. Standards on Access and Continuity of Care.
V. Standards on Quality Improvement There are seven (7) criteria that guide the nurses
Standard I. Leadership and Staff Education regarding the importance of access to care. These
Standard II. Quality Programs
standards identify the need to establish policies and
Standard III. Quality Monitoring, Analysis and Implementation
procedures from admission to discharge and referral
follow up.
needed in the delivery of nursing services and
training of personnel to effectively carry out their
respective roles.

V. Standards on Nursing Documentation. There are IV. Standards on Communication Management.

two identified criteria under this component, which Three (3) criteria are identified focusing on the
include documentation of significant data both patient’s record, administration record and
structure, and clinical based on applicable laws and communication of information. It also enables the
regulations, professional standards and institutional chief nurses/administrator to develop a specific
requirements. hospital system which is efficient and effective.

The second part is the Administration and Management. V. Standards on Quality Improvement. This
This concerns managing the nursing services in the hospital. standard has three (3) criteria which address the
There are five (5) standards identified: need to institutionalize continuous quality and
performance improvement.
I. Standards on Governance and Direction. There
are seven (7) criteria included. This chapter Each standard and criteria has identified measurable
recommends the need for organizational structure elements intended to provide clarity to the standards and to help
which will delineate responsibility, accountability organizations develop their own policies and procedures
and authority of nursing administration. These focus according to the standards.
also on planning, direction, organization and
controlling functions of the nursing service
administration and their relationship with other

II. 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

III. Standards on Facility Management and

Environmental Safety. This standard contains
three (3) criteria and covers environmental safety
3. Those responsible for direct nursing care collaborate
with medical and allied staff to analyze and integrate
the patient’s assessment data and information.
4. Those responsible for direct nursing care prioritize
patients’ needs based on assessment results.
5. Those responsible for direct patient care inform the
patient and family of the assessment outcome and
the planned care and treatment regimen and
CLINICAL SERVICES encourage participation of the latter in the decision-
making about the priority needs to be met.
I. Standards on Assessment of Care
Standard II: Assessment Scope & Content
Standard I: Assessment Process
The scope and content of nursing assessment are well
The nurse identifies the health care needs of each patient defined in an institutional policy wherein those elements
based on an established assessment process and within the common to all assessments and any differences with other
prescribed timeframe. health disciplines are identified.

Measurable Elements Measurable Elements

1. There is an evidence of initial and completion of 1. There is a well defined policy on nursing assessment
nursing assessment on the health care needs of each in terms of scope and content which include but are
patient within the: not limited on the following:
1.1.1st 24 hours of admission as an in-patient or 1.1. Psychological
earlier as indicated by the patient’s condition or • Knowledge level
institutional policy. • Language spoken
1.2.1st 2 hours of consultation as an outpatient or • Barriers to learning
earlier as indicated by patient’s condition or 1.2. Physical
institutional policy. • Neurological assessment
2. There is an evidence of patient’s reassessment • Cardiovascular assessment
throughout the care process to determine response to • Respiratory assessment
intervention at interval appropriate to patient’s • Gastrointestinal assessment
condition, plan of care, individual needs or • Genitourinary assessment
according to institutional policies and procedures • Musculoskeletal assessment
(e.g. Pain is assessed every 4 hours and as necessary
• Intergumentary assessment
as part of the vital signs monitoring).
• Sensory assessment 2.11.Value – Belief Pattern
1.3. Social 3. Other pertinent data are collected using the
• Cultural concerns appropriate assessment, technique and instruments.
1.4. Spiritual
• Religion
1.5. Economic factor
• Financial barrier
4. The nursing assessment findings are documented in
the individual patient’s record and readily available
1.6. Health history to those responsible for his/her care.
5. Discharge plan is evident in the initial assessment of
• Developmental history (for pediatrics)
the nurse particularly to those patients when
• Family history
discharge planning is critical as evidenced by the
• Medications taken following:
• Allergies 5.1. Age
1.7. Vital signs 5.2. Lack of mobility
1.8. Pain assessment 5.3. Continuing medical and nursing needs
1.9. Nutritional status, needs and risks 5.4. Assistance with activities of daily living
1.10.Preference and idiosyncrasies 5.5. Referral for continuity of care as necessary
1.11.Discharge plan
• Place: home, extended, skilled care II. Standards on Care of Patient
• Individual who will accompany the patient Standard I: Care Process
home (name, address, telephone number,
relationship) The Nursing Services Department has an established
2. There is an established screening criteria according uniform care process across the clinical setting that reflects
to patients’ functional capacity and needs like: integration and coordination of care of other health team
2.1. Nutritional – Metabolic Pattern members particularly to those patients with similar
2.2. Elimination Pattern condition.
2.3. Activity – Exercise Pattern
2.4. Sleep – Rest Pattern Measurable Elements
2.5. Sexuality – Reproductive Pattern
2.6. Sensory – Perceptual Pattern 1. There are existing policies and procedures on care
2.7. Cognitive Pattern process developed by those responsible for
2.8. Role – Relationship Pattern governance which include but are not limited on the
2.9. Self – Concept Pattern following:
2.10.Coping – Stress Tolerance Pattern
1.1. Care of emergency patients (including use 1. There is a written care plan on every patient cared of
of resuscitation equipment) by the nurse based on patient’s initial assessment
1.2. Care of patient on life support (e.g. data within the 1st 24 hours of assessment or earlier.
ventilatory equipment) 2. There is an evidence that family and significant
1.3. Care of patient on dialysis (hemodialysis, others are involved in the planning process.
peritoneal dialysis) 2.1. Patient participate in planning of care taking
into consideration the cultural, religious and
other beliefs of patients. Example:
1.4. Care of patients at risk: Selection of food
• Neonates • Critically-ill 3. The care plan reflects the related and relevant
• Children • Mentally disadvantaged identified needs and problems of each patient cared
• Elderly • Under anesthesia for.
• Disabled 4. The care plan ensures that priorities of care are
1.5. Care of comatose patient established.
1.6. Care of patient with communicable diseases 5. The care plan is updated as appropriate based on the
1.7. Care of patient in restraint reassessment made.
1.8. Care of patient on chemotherapy 6. The care plan is documented in the individual
1.9. Care of immune - suppressed patients patient’s record to promote continuity of care.
1.10. Care of patient in pain
1.11. Care of patient on nutritional therapy Standard III: Implementation of Care
1.12. Care of patient receiving blood and blood
components The nurse caring for patients implements nursing
1.13. Care of patient receiving medications with intervention and carries out medical orders utilizing critical
narrow margin of safety thinking and sound clinical judgment for the promotion of
1.14. Care of perioperative patient health, prevention of illness, alleviation of suffering and
1.15. Care of patient with intravenous therapy restoration of health.

Standard II: Care Plan Measurable Elements

The nurse caring for patients develops and updates an 1. There is an evidence that nurse caring for patients
individualized written care plan in the patient’s record within implements nursing intervention and carries out
the prescribed time frame. medical orders utilizing critical thinking and sound
clinical judgment based on but are not limited on the
Measurable Elements following:
1.1. Scope of Nursing Practice as provided by law The nurse caring for patients systematically and
and all relevant legislations (e.g. The Philippine continuously evaluates the patient’s progress based on the
Nursing Act of 2002 or Republic Act 9173) effectiveness of nursing intervention rendered and medical
management provided.

1.2. Standard of Care:

• Acute and Critical Care Nursing Practice Measurable Elements
• Chronic Care Nursing Practice
• Cardiovascular Nursing Practice 1. Systematic and continuous evaluation of patient’s
• Perioperative Nursing Practice progress and effectiveness of care is reflected in the
individualized patient record.
• Maternal and Child Nursing Practice
2. There is an evidence that evaluation of care and
• Psychiatric Nursing Practice
patient outcome occurs within an appropriate time
• Emergency Nursing Practice frame after the intervention (nursing or medical) is
• Renal Nursing Practice initiated.
• Pediatric Nursing Practice 3. There is an evidence that patient’s responses to
• Oncology Nursing Practice interventions are documented.
• Geriatric Nursing Practice 4. The revision in care plan if any is reflected in the
• Ethical and Legal Nursing Practice patient record.
• Nursing Standard on Intravenous Therapy
• Infection Control Nursing Practice Standard V: Pain Management
1.3. Evidence - based practice
1.4. Ten (10) Golden Rules in Drug Administration The Nursing Services Department has established pain
1.5. Code of Ethics for Nurses management guidelines for nurses to appropriately assess,
1.6. Patient Bill of Rights monitor, evaluate and manage patients in pain.
2. It is evident that implementation of
interventions/care is delivered in a safely manner Measurable Elements
that minimizes complications and life-threatening
situations. 1. There is an existing pain management guideline for
nurses to appropriately assess, monitor, evaluate and
Standard IV: Evaluation of Care 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 Standard VII: End-of-Life Care

The Nursing Services Department has established The nurse provides an end-of-life care to facilitate a
policies, procedures and guidelines on medication dignified and peaceful closure of life for patients through
management for symptomatic, curative, preventive, and physiological, psychological, social and spiritual care taking
palliative treatment of patients’ diseases and for safe nursing into consideration the cultural diversities in beliefs and
practice. customs and optimize caring environment.

Measurable Elements Measurable Elements

1. There are written policies, procedures and guidelines 1. Respect for patient’s values, religion and cultural
on medication management which include but are preferences and practices is evident.
not limited on the following: 1.1. Pastoral services are provided based on the
1.1. Carrying out physician’s medication order spiritual beliefs of the patient and family.
1.2. Transcribing and ordering 1.2. The patient’s right of self-determination and
1.3. Endorsing (especially high valuable drugs) choices are respected and accommodated.
1.4. Preparing 1.3. Advance directives Do Not Resuscitate, Waiver,
1.5. Labeling Living will if any, are respected.
1.6. Administering (10 Golden Rules in Drug 1.4. Patient and family choices to donate organs and
Administration) other tissue are supported through provision of
1.7. Documenting relevant information. In accordance to statutory
1.8. Monitoring and Storage laws, rules and regulations.
1.9. Emergency Drugs 2. Assessment, appropriate intervention to alleviate the
1.10.Regulated Drugs patient’s pain and discomfort according to wishes of
1.11.Medication Recall System (Expired or patient and family and re-assessment are evident.
Outdated Drugs) 2.1. Pain assessment, intervention and evaluation,
1.12.Reporting on are monitored and recorded.
• Medication effects and adverse effects 2.2. Personal hygiene is rendered based on patient’s
• Medication error and near-miss need.
2.3. Nutritional assessment and risks are identified 1.7. Support patient and family rights by
and nutritional needs are provided such as participating in the care decision and care
feeding and hydration. process through information of the following:
2.4. Interventions address patient and family’s • Medical condition and confirmed
psychosocial, emotional, spiritual and cultural diagnosis and the informant
concerns. • Planned care, treatment, outcome of care,
3. A place is designated for the patient’s family to stay. unanticipated outcome and participation in
4. The patient and family are involved in care care decision according to wishes
management and decision. • Informed consent
• Refusal or discontinuance of treatment
Standard VIII: Patient and Family Rights • Withholding life-sustaining treatments
• Assessment and management of pain
The Nursing Services Department has established
policies, processes and guidelines that respect and support • Compassionate care at the end-of-life
patient and family rights. • Process on complaints and differences of
opinion about patient care
Measurable Elements • Participation in clinical research
• Organ donation and other tissues
1. There are written policies, processes and guidelines • Disclosure of information
that respect and support patient and family rights 2. There is evidence that nurses are knowledgeable and
which include but are not limited on the following: supportive of patient and family rights.
1.1. Prerogative to determine what information
regarding health condition and care is provided III. Standards on Patient and Family Education
to family and under what circumstances.
1.2. Respect for patient’s personal values and beliefs Standard I: Education Assessment
1.3. Respect the confidentiality of patient health
information The nurse assesses the educational needs of each patient
1.4. Respect for patient’s need for privacy (e.g. and family and documents these in his/her patient record.
during treatment, procedure, physical
examination, clinical interview, transport) Measurable Elements
1.5. Protection of patient’s possessions from theft or
loss 1. There is a written evidence that the nurse assesses
1.6. Protection of patient from physical assault (e.g. the educational needs of each patient and family
vulnerable patients are infants, children and which include but are not limited on the following:
elderly) 1.1. Patient’s and family’s beliefs and values
1.2. Patient’s and family’s literacy
1.3. Patient’s and family’s educational level
1.4. Patient’s and family’s language 5. It is evident that standardized materials and
1.5. Patient’s and family’s motivations and processes in educating patient and family on the
emotional barriers aforementioned topics (4.1 to 4.5) are available.
1.6. Patient’s physical and cognitive limitation 6. There is an evidence that nurses who provide
1.7. Patient’s willingness to receive information education have the subject knowledge, adequate
Standard II: Education Plan and Programs time and communication skills to do so.

The Nursing Services Department has established IV. Standards on Access and Continuity of Care
educational plans and programs that support patient and
family participation in care decisions and care processes Standard I: Access to Care
with the primary objective of rehabilitating the patient back
to his/her functional level and optimal health. In diverse health care setting, the Nursing Services
Department has established policies and processes on patient
Measurable Elements access to care aligned with the organization.

1. The educational plan and programs for patient and Measurable Elements
family are evident according to the type of patient
served and his/her learning needs. 1. The written policies and processes on patient access
2. The appropriate structure, methods and mechanism to care are evident which include but are not limited
for education is afforded. on the following:
3. Education resources are available and organized in 1.1. Clinical services available
an efficient and effective manner. 1.2. Triage or screening
4. When appropriate, it is evident that the patient and • There is evidence that triaging or
family are educated on topics considered high risk to screening is initiated at the point of 1st
patients: contact with the patient
4.1. Safe and effective use of medications and their 1.3. Criteria for admitting patient or registering
side effects out patient
4.2. Preventing interactions between prescribed 1.4. Process for admitting patient or registering
medications and other medications (over the out patient
counter) and food 1.5. Holding area for patient on observation
4.3. Safe and effective use of medical equipment 1.6. Managing patient when bed or space or
4.4. Pain management facilities is not available
4.5. Rehabilitation techniques
4.6. Treatment and diagnostic procedures Standard II: Emergency Patients
The patients with emergency or immediate needs/care 2.1. Proposed plan of care
are given priority for assessment and treatment by the nurse. 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 overcome barriers such as language,
cultural, physical, to access and in the delivery
of care
Measurable Elements Standard IV: Intensive and Specialized Services

1. There is an evidence that patients with immediate The Nursing Services Department has established entry/
needs/care are assessed, prioritized and received the or transfer criteria for patients that need intensive and
necessary care as quickly as possible according to specialized services to meet special patient needs congruent
established physiologically based criteria. with those of the organization.
2. There is an evidence that staff who responded to
emergency patients underwent the necessary Measurable Elements
1. There is an evidence of entry/or transfer criteria for
Standard III: Admitted Patients or In-Patients patients that need intensive and specialized services
to meet special patient needs.
The needs of in-patients for preventive, curative, 2. It is evident that criteria is physiologic-based and
rehabilitative and palliative services as well as other relevant developed by appropriate individuals.
information are assessed and prioritized based on his/her 3. It is evident that patients admitted and or transferred
health condition at the time of admission in the health care to intensive and specialized areas/units meet the
facility. established criteria and are documented in the
patient record.
Measurable Elements 4. There is an evidence that nurses caring for patients
needing intensive and specialized services
1. There is an evidence that nurse screening assessment underwent the related and necessary training.
focuses on preventive, curative, rehabilitative and
palliative services and prioritizes these according to Standard V: Continuity of Care
the patient’s health condition.
2. There is an evidence that nurse actively participated In diverse health care setting, the Nursing Services
in providing relevant information to patient and Department has established policies and processes on patient
family during the admission process which includes continuity of care aligned with those of the organization and
but are not limited on the following: coordinated among other health professionals.
2. There are criteria that determine patients readiness to
Measurable Elements be discharged.
3. There is a process on out on pass patients for a
1. The written policies and processes on patient defined period of time.
continuity of care are evident and implemented 4. There is a referral system of patients for transfer to
throughout all phases of patient care particularly but other organization.
are not limited in the following services: 5. The patient’s discharge summary is prepared by
qualified individuals recognized by the organization.
1.1. Emergency services to nursing ward admission 6. A copy of patient’s discharge summary is placed in
1.2. Nursing ward services to diagnostic services the patient record and another copy is given to the
1.3. Nursing ward services to surgical and non- patient which include but are not limited on the
surgical services following:
1.4. Between nursing units or clinical departments 6.1. Reason for admission
1.5. Nursing ward services to intensive or special 6.2. Significant physical and other findings
services 6.3. Significant diagnosis and co-morbidities
1.6. Out patient care programs 6.4. Diagnostic and therapeutic procedures
1.7. Other health care settings performed
2. During all phases of care, there is a qualified 6.5. Medications and treatments
individual, identified as responsible for patient care 6.6. Medications to be taken at home
and documented in the patient record. 6.7. Condition of patient at the time of discharge
3. Continuity of care and coordination of services are 6.8. Follow-up instruction in an understandable form
evident throughout all phases of care. and manner
• Activity
Standard VI: Discharge, Out on Pass, Referral and • Diet
Follow-up • Next medical consultation
• Urgent care indicators
The Nursing Services Department has established 6.9. Referral for support services to either health care
policies and processes and guidelines on patient’s discharge, providers, health organizations or agency, and
out on pass, referral and follow-up congruent with those of health professionals in the community.
the organization.
Standard VII: Transfer of Patient
Measurable Elements
The Nursing Services Department has established
1. There are written policies, procedures and guidelines policies, procedures and guidelines regarding the transfer of
on patient’s discharge, out on pass, referral and patient within and outside of the organization.
follow-up congruent with those of the organization.
Measurable Elements applicable forms which include but are not limited
on the following:
1. There is a written policy, procedure and guidelines 1.1. Patient’s addressograph – name, age,
on transfer of patient within and outside of the gender, civil status
organization. 1.2. Registration number and or Admission
2. The guidelines and procedures include but are not number
limited on the following: 1.3. Date and time of admission and discharge
2.1. Transfer is based on the patient’s needs for 1.4. Mode of admission/transport/discharge
continuity of care. 1.4.1. Admitted via: ambulatory,
2.2. Transfer of responsibility to another health wheelchair, stretcher
provider or health care setting is evident. 1.4.2. Admitted from: home, transferring
2.3. Responsible health care provider during the hospital, care facility
patient’s transfer is identified. 1.5. Attending physician and referring physician,
2.4. Formal and informal arrangements are apparent. if any
2.5. Summary of patient’s clinical condition, 1.6. Religion
interventions (medical and nursing) and 1.7. Language spoken
continuous care rendered are written. 1.8. Advance directive
2.6. Situation when transfer is not possible is stated. 1.9. Health Care Insurance
2.7. Patient’s transfer is documented.
2.8. Safe and quality medical transport services Standard II: Clinical Data
within and outside of the organization are
provided. The nurse documents essential clinical data of each
patient accurately and completely based on individualized
V. Standards on Nursing Documentation nursing care plan from admission to discharge in health care
Standard I: Structural Data
Measurable Elements
The nurse documents structural data of each patient
accurately and completely based on applicable laws and 1. There is relevant/essential, accurate and complete
regulations, professional standards and institutional nursing documentation of patients’ clinical data in
requirements. all appropriate forms from admission to discharge
in health care facility which include but are not
Measurable Elements limited on the following:
1.1. Physical examination (head-to-toe)
1. There is an accurate and complete documentation 1.2. Health history
of patients’ structural data in all nursing and
1.3. Psychological, social, spiritual and
economic evaluation
1.4. Actual and potential health problems and ADMINISTRATION & MANAGEMENT
1.5. Diagnostic and therapeutic interventions
I. Standards on Governance and Direction
1.6. Pharmacological management
1.7. Nursing interventions
Standard I: Governance Structure
1.8. Health teachings – patient and family
1.9. Patients’ response and outcome
The Nursing Services Department has governance
1.10. Preferences and idiosyncrasies
structure designed to delineate lines of relationship,
authority, responsibility and accountability and the
mechanisms for communication and coordination within the
Nursing Services and other services/departments of the
health care facility.

Measurable Elements

1. The Nursing Services governance structure is

represented or displayed in an organizational chart
that shows functional and positional relationships
and span of control.
2. The Nursing Services governance structure is
described in written documents with the approval of
proper authority.
3. The Nursing Services governance structure depicts
decentralization or unit-based wherein decision-
making prevails to support and promote patient
safety and quality improvement.
4. The Nursing Services governance structure and
processes support professional communication,
clinical planning and services and policy

Standard II: Governance Responsibility and

The governance responsibility and accountability are time bound, ethical and recorded), reviewed,
described in a written document to guide how they are to be updated, widely disseminated, interpreted and
carried out. operationalized.
Measurable Elements Standard IV: Strategic & Operational Plans

1. The governance responsibility and accountability are The Nursing Services Department has documented
described in organization’s by-laws, job description strategic and operational plans consistent with the hospital
and other similar documents. wide quality plan.
2. Those responsible and accountable for governing
and managing the Nursing Services Department are Measurable Elements
identified by position title and name.
3. Those responsible for governance appoint the 1. Those responsible for governance forecast and direct
Nursing Services Administrator, managers, the future and operation of the Nursing Services
professional technical staff and assistive nursing Department in order to achieve its overall goals.
personnel to carry out the functions of the Nursing 2. There is an existence of strategic and operational
Services Department. plans periodically set and reviewed which contains
4. There is a written document that describes how the goals and objectives, action plan/activities,
performances of the governing entity are appraised timeframe, resources required and contingencies.
by specific criteria. 3. Those in the managerial and clinical levels translate
the overall Nursing Services Department’ strategic
Standard III: Direction-Setting and management plans into action which include:
the management of patient care, nursing manpower
The Nursing Services Department has an established and unit operation of responsibility areas.
vision, mission, philosophy, core values and quality
objectives congruent with that of the institution and the Standard V: Financial Plan & Resource Allocation
Nursing profession.
The Nursing Services Department has financial plan and
Measurable Elements allocation of resources required to meet its goals and sustain
its operation.
1. Those responsible for the Nursing Services
Department governance, primarily sets its direction Measurable Elements
by formulating its vision, mission, philosophy, core
values and quality objectives congruent with that of 1. Those responsible for governance have established
the institution and the Nursing profession. current financial plans and allocation of resources
2. The vision, mission, philosophy and core values are based on the needs of the Nursing Services
written (specific, measurable, attainable, reliable, Department.
2. The capital and operating budgets are implemented conforms with the applicable statutory laws, rules and
as approved by the authorized person/office and regulations.
monitored based on responsibility accounting.
3. Each Nursing Unit has an individual budget plan
periodically monitored for variances. Measurable Elements
4. The medical supplies, materials and equipment
recommended by professional organizations and 1. Those responsible for governance formulate policies
authoritative sources are obtained and appropriately and procedures to serve as guidelines for those
used. confronted by ethico-moral dilemmas in patient care.
2. Those responsible for governance ensure compliance
Standard VI: Policies & Procedures Development with the applicable statutory laws, regulations and
The policies and procedures of the Nursing Services 3. The Nursing Services Department has a written
Department that reflect Standards of Nursing Code of Ethical Behavior which observes the rights
Administration, Nursing Practice on Patient Care are and safety of patients and health care providers.
developed and communicated to serve as operational
guidelines. Standard VIII: Professional & Organizational
Measurable Elements
The administrator of the Nursing Services Department
1. Those responsible for governance develop and actively participates and collaborates with leaders within the
implement policies and procedures based on organization and professional associations for continuous
established Standards of Nursing Administration and quality improvement of nursing services.
Nursing Service on Patient Care.
2. An updated manual of Nursing Services policies and Measurable Elements
procedures exists and provides clear directive for
nursing personnel at different levels on the scope 1. Those responsible for Nursing Services Department
and limitations of their functions and responsibilities governance initiate and maintain formal
to patient care. liaison/linkage with other departments/sections of
the institution and professional associations and
Standard VII: Ethico – Moral & Legal Accountabilities agencies pertinent to nursing standards and
practices, professional and interprofessional
The Nursing Services Department has an established relationships and other related endeavors.
framework for ethico-moral and legal management to
support the ethical decision-making in the clinical areas, and
administration courses at the graduate
level; and
1.1.4. Be a member of good standing of the
accredited professional organization
of nurses.
II. Standards on Human Resource Management
1.2. A person occupying the position of chief nurse
Standard I: Administrator of Nursing Services of director of nursing service shall, in addition
to the foregoing qualifications, possess:
The Nursing Services Department is administered by a 1.1.1. At least five (5) years of experience
qualified nursing administrator pertinent to licensure, in a supervisory or management
appropriate education, experience and demonstrable proven position in nursing; and
ability in nursing practice and administration, fully 1.1.2. A master’s degree major in nursing.
responsible and accountable for the operation of the entire 1.3. That for primary hospitals, the maximum
Nursing Services of the organization/institution. academic qualifications and experiences for a
chief nurse shall be as specified in subsections
Measurable Elements (1.1.1), (1.1.2.), and (1.1.3) of the above.
1.4. That for chief nurses in the public health
1. There are presence of evidences that the Nursing agencies; those who have a master’s degree in
Service Administrator is qualified to the position public health/community health nursing shall
based on RA 9173 and other criteria set by the be given priority.
organization/institution such as: 1.5. That for chief nurses in military hospitals,
1.1 Qualifications of Nursing Service priority shall be given to those who have
Administrators: finished a master’s degree in nursing and the
A person occupying supervisory or completion of the General Staff Course
managerial positions requiring knowledge of (GSC).
nursing must: 2. Those responsible for the overall administration
1.1.1. Be a registered nurse in the and management of Nursing Services is a member
Philippines; of the top Executive/Management Committee who
1.1.2. Have at least two (2) years experience participates in their regular meetings and provides
in general nursing service advice and recommendations in relation to nursing
administration; practice.
1.1.3. Possess a degree of bachelor of
Science in Nursing, with a least nine Standard II: Staffing Plan
(9) units in management and
The Nursing Services Department has a staffing plan development of system and processes for
that identify the number, type and desired qualification of recruitment, selection, hiring, appointment and
nursing services staff which is written, reviewed and updated promotion of nursing service personnel in
on an ongoing basis. accordance with the statutory laws and regulations
and the institutional policies and procedures.
2. There are legitimate and legitimized processes to
recruit, select, hire and appoint nursing services
Measurable Elements personnel and are uniformly implemented.
3. Staff recruitment, selection, hiring and appointment
1. Those responsible for Nursing Services governance are based on institutional, patients’ needs and
develop a staffing plan that identify the number, type applicant qualification.
and desired qualification (education, skills and
experience) of Nursing Services staff, reviewed and Standard IV: Credentialing
updated on an ongoing basis.
2. Those responsible for Nursing Services governance The Nursing Services Department has an effective
consider the organization’s mission, type of services, process for gathering, verifying and evaluating the nursing
level and modality of care, patients’ mix, staff and staff credentials.
skills mix and other factors affecting the projection
of staffing needs. Measurable Elements
3. The staffing plan is defined in writing and meets the
needs of the patients/population served and scope of 1. Those responsible for Nursing Services governance
services. develop an effective process for gathering, verifying
and evaluating the nursing staff credentials
Standard III: Recruitment, Selection, Hiring and (licensure, education, training, work experience) and
Appointment other pertinent requirements.
2. There is evidence of standardized procedure to
The Nursing Services Department has an established gather the credentials of all nursing staff.
system and processes for recruitment, selection, hiring, 3. The licensure, education, training and work
appointment and promotion of human resources in experiences of nursing personnel are documented
accordance with the statutory laws and regulations and the and updated.
institutional policies and procedures.
Standard V: Staff Placement
Measurable Elements
The Nursing Services Department has defined criteria
1. Those responsible for the Nursing Services and processes to ensure the clinical staff knowledge and
governance actively participate/collaborate in the skills are consistent with the patients’ needs.
2. There is evidence that the Job Description of
Nursing Services personnel is reviewed at least once
every 3 years and revised when necessary.

Measurable Elements

1. Those responsible for Nursing Services governance Standard VII: Staff Development
develop and define the criteria (core competencies)
and processes to match the clinical staff knowledge The Nursing Services Department has an established
and skills with the patients’ needs. staff development program for all nursing personnel to
2. There are written core competencies required for encourage and promote continuing personal and professional
every job position in the Nursing Services growth and development.
organization to ensure that the staff skills are
consistent with the patients’ needs. Measurable Elements
3. Staff placement/assignment is based on patient
needs, available resources and staff competencies. 1. Those responsible for Nursing Services governance
design and implement staff development programs
Standard VI: Staff Job Description for nursing personnel at all levels based on training
needs analyses.
The Nursing Services Department has job description for 2. There is evidence of staff development programs for
each position classification of Nursing personnel, which all nursing personnel throughout the year which
specifies duties and responsibilities based on established include:
standards of performance. a. Orientation program for newly hired and
promoted staff, to the organization
Measurable Elements department/unit to which they are assigned as
well as their specific job responsibilities.
1. There is a written Job Description for each position b. Safety program to protect the patient, staff and
classification of Nursing Services personnel which property.
specifies: c. Continuing education, training and opportunities
1.1. Duties and responsibilities for professional advancement of staff member to
1.2. Accountability enhance their knowledge and skills.
1.3. Functional relationship d. Career counseling and career
1.4. Qualification and experience required advancement/ladder.
3. Resources are available to implement the staff
development program such as:
3.1. Space and facilities 2. Those responsible for governance actively
3.2. Educational resources participate in space planning as well as medical
3.3. Clinical and clerical staff equipment and supplies procurement.
3.4. Audiovisual equipment 3. Those responsible for governance, plan and budget
3.5. Resource speakers for upgrading or replacing key components based on
facility inspection findings.

4. Policies and procedures on continuing education Standard II: Environmental Safety

staff attendance to staff development programs are
evident. The Nursing Services Department actively participates
5. Records of staff development program are in the planning, implementation and evaluation of hospital –
maintained which include: wide programs to provide a safe and secure physical
5.1. Title of the program environment.
5.2. Objectives of the program
5.3. Program design and content Measurable Elements
5.4. Evaluation of the attendees
5.5. Effectiveness of the program 1. There is a written and up-to-date plan,
5.6. List of attendees/participants implementation and evaluation of
programs/activities to manage the risks within the
III. Standards on Facility Management & Environment environment which includes but is not limited on the
Safety following:
1.1. Safety and Security
Standard I: Facility Planning • There is an existing provision for the
identification of patient and their families,
For efficient and effective delivery of nursing care and visitors, staff and others.
services, the Nursing Services Department provides a safe, • Monitoring mechanism of all risk areas is
functional and supportive facility to patients and their in place and kept secure to patient from
families, staff and visitors aligned with that of the unauthorized access or use, tampering,
organization’s master plan. destruction or loss. (e.g. Medication
Measurable Elements
1.2. Hazardous Materials and Waste
1. Those responsible for governance comply with • There is a current list of hazardous
relevant laws, regulations and other requirements materials and waste to safely control them
that are applicable. (e.g. chemotherapeutic agents, chemicals,
radio-active materials and waste,
hazardous gases and vapors, infectious institutional emergencies, epidemics, and
waste). disasters.
• There is an existing written processes on
handing, labeling, storage, use, inventory
and disposal of hazardous materials and
• Documentation and reporting system are
in place for investigation of spills, 1.6. Fire Safety
exposures and other accidents related to • There is an evidence that fire safety plan
hazardous materials and wastes. and program of the
organization/institution is implemented in
1.3. Medical Equipment a continuous and comprehensive manner
• There is an updated policy and processes to all patient care and staff work areas.
on medical equipment procurement,
inventory, regular inspection, preventive 1.7. Infection Control
maintenance, and recall system. • There is evidence that policies, procedures
• Monitoring of equipment functionality and and guidelines on infection control are
utilization is in place for purposes of implemented.
planning and improvement. • There are infection surveillance,
prevention and control programs to
1.4. Utilities identify and reduce the risks of acquiring
• Potable water, electrical power, and and transmitting infections among patients
medical gases are available 24 hours a and nursing staff.
day, seven (7) days a week. • There is evidence that the nursing staff is
• A written emergency processes is in place provided with education on infection
in the event of water interruption or control practices.
contamination, electrical failure or
interruption and medical gases Standard III: Staff Education
• Monitoring of utilities is evident for The Nursing Services Department ensures education and
purposes of planning and improvement. training of staff to effectively carry out their roles in creating
a safe and sound patient and staff environment.
1.5. Emergencies
• An emergency management plan and Measurable Elements
processes are evident to likely community/
1. There is an evidence of staff education and training • Educational materials and methods in an
on facility management and environmental safety understandable format and language
2. There is an evidence that the staff can describe and 1.3. Nursing Personnel
demonstrate their role in the aforementioned safety • Nursing endorsement in between work
programs. shifts
3. There is an evidence of staff training to operate • Nursing documentation
medical equipment appropriate to their job • Referral
description. • Nursing Service Philosophy, Vision,
Mission, Core Values
VI. Standards on Communication Management
• Policies, Procedures, Guidelines,
Standard I: Communication of Information
• Memorandum, Circular, Directives,
The Nursing Services Department has efficient and Activities
effective system of communication with the community, to
patients and their families, nursing personnel and other 1.4. Other Health Professionals (clinical and non-
health professionals throughout the organization. clinical staff)
• Patient care and response to care (referral)
Measurable Elements • Patient clinical data (diagnostic
examinations and therapeutic procedures)
1. There is efficient and effective system of • Circular
communication that exist which include but are not
limited on the following: Standard II: Patient Clinical Record
1.1. Community
• Patient/nursing care services The Nursing Services Department has established
• Health programs policies, procedures and guidelines on patient clinical record.
• Process to access care
Measurable Elements
1.2. Patients and Families
1. There are written policies, procedures, and
• Patient health condition
guidelines on patient clinical record which include
• Care provided to patient but are not limited on the following:
• Patient’s response to care 1.1. Clinical record for every patient assessed or
• Patient/nursing care services available treated, in-patient or out-patient
• Alternative sources of care and services 1.2. Confidentiality of record
• Process to access care 1.3. Security of record
• Protection from loss and destruction and 1.11.Quality Improvement Program and other
unauthorized access and use Projects
1.4. Data Integrity 1.12.Manuals of the Organization
• Protection from tampering • Quality System
1.5. Use and monitoring of standardized • Infection Control
abbreviations, symbols, procedure codes and • Emergency Preparedness
definitions • Employees’ Manual
1.6. Retention period of records (as prescribed by • Others
law and institutional policy) 2. There is written policy or protocol in developing and
maintaining policies and procedure which include
Standard III: Administrative Record but are not limited on the following:
2.1. Review and approval of all policies and
The Nursing Services Department has established procedures before implementation
policies or protocol in keeping and maintaining its 2.2. Process and frequency of review and continued
administrative record and defining the requirements for approval of policies and procedures
developing and maintaining policies and procedures. 2.3. Control that only current policy and procedures
are implemented
Measurable Elements 2.4. Identification of charges in policy and
1. There is a written policy or protocol in keeping and 2.5. Retention of obsolete policies and procedures
maintaining Nursing Services Department 2.6. References originating outside the organization
administrative records which include but are not 2.7. Tracking of policy and procedures in circulation
limited on the following: (e.g. title, date of issue, authorized person)
1.1. Organization and Nursing Services Department
Policies, Procedures, Guidelines V. Standards on Quality Improvement
1.2. Standards
1.3. Master Staffing Plan Standard I: Leadership and Staff Education
1.4. Staffing Pattern
1.5. Census of Patients and Diseases The Nursing Services Department has continuous quality
1.6. Bed Capacity and Occupancy Rate improvement on patient and staff safety programs through
1.7. Budget Plan monitoring and analyzing variation of data and undesirable
1.8. Staff Development Programs trends of events.
1.9. Committees, Nursing and the Organization
1.10.Minutes of Meeting, Nursing Services Measurable Elements
1. Those responsible for governing and managing the and other relevant evidence – based information.
Nursing Service Department lead or actively (e.g. Medication safety, clinical pathway)
participate in planning, monitoring, analyzing and 2. There is an existing plan and program to reduce the
implementing quality improvement and patient and risk of community/hospital acquired infectious for
staff safety programs congruent with the patients and health care associated infections for
organizational needs. staff.
2. There is an evidence that information on quality 3. There is an evidence that the quality
improvement and patient and staff safety programs improvement/processes and safety programs are
are communicated to staff on a regular basis through approved by governance, implemented and
effective channels inclusive of progress on monitored for consistent use and effectiveness.
3. There is a training program for staff consistent with Standard III: Quality Monitoring, Analysis &
their role in quality improvement and patient safety Implementation
4. There is a qualified trainer who provides the training The Nursing Services Department has established key
and staff participation as part of their regular work indicators to monitor the clinical and managerial structure,
assignment. processes and results and data are aggregated, analyzed and
5. There is an established reporting system on the transformed to useful information.
quality and safety programs to governance.
6. Those in governance support and take action on Measurable Elements
recommendation for quality improvement and
patient and staff safety programs based on the result 1. There is a clinical monitoring that exists but is not
of root cause analysis. limited on the following:
1.1. Clinical research
Standard II: Quality Programs 1.2. Nursing documentation
1.3. Medication error
The Nursing Services Department has priority quality 1.4. Intravenous fluids
programs to reduce high volume, high risk and problem- 1.5. Blood and blood products
prone processes. 1.6. Total parenteral nutrition
1.7. Surgical safety (sterilization/disinfection)
Measurable Elements 1.8. Infection control, surveillance, reporting (needle
stick injury, hand hygiene and barrier technique,
1. There is written plan or policy or document of a well body fluids and waste segregation/disposal)
designed new processes or modified existing 1.9. Prevention and control measures aligned with
processes consistent with current practice, International Patient Safety Goals. (Isolation
guidelines, clinical standards, scientific literature, Procedure)
2. There is a managerial monitoring that exists but is
not limited on the following:
2.1. Patient demographics and clinical diagnoses
2.2. Patient and family expectations and complaints, GLOSSARY
if any
2.3. Availability of drugs and medical supplies
essential to most patient needs (e.g. Emergency Adverse Event – is an unanticipated or potentially
Kart contents) dangerous occurrence in health care organization.
2.4. Financial budget
2.5. Manpower utilization Clinical Pathways – is an agreed-upon treatment regime
2.6. Staff expectations and satisfaction that includes elements of care.
2.7. Incident reports and sentinel events
2.8. Reports as required by law and regulation and Communication Management – is the creation, use,
those in governance sharing and disposal of data or information for effective and
3. There is an evidence data analysis and actions taken. efficient operation of organization activities. It includes the
4. There is an evidence that actions for improvement role of management to produce and control the use of data
are appropriate to the care, scope and severity of the and information in work activities, information resources
problems. management, information technology, and information
5. There is an evidence that the actions for services.
improvement or changes are planned, tested and
implemented. Continuity of Care – is the matching of an individual’s
6. There is a written available data to demonstrate that ongoing needs with the appropriate care setting; level of
the improvements are effective and sustained. medical, psychological, or nursing care; or spiritual and
social care or service. This applies within an organization or
across multiple organizations.

Credentialing – is the process of obtaining, verifying, and

assessing the qualifications of a health care practitioner like
the nursing personnel. The process determines if an
individual can provide patient care services in or for a health
care organization.

Discharge Summary – is a section of patient record that

summarizes the reasons for admittance, the significant
findings, the procedures performed, the treatment rendered,
the patient’s condition on discharge, and other specific
instructions given to the patient or family (for example, physician or other health care professional begins the
follow –up, medications). procedure or treatment.
End-of-Life Care – is the provision of care to the patient
whose disease condition is not responsive to curative In-Service Education – is an organized education, usually
treatment, and his/her life expectancy is estimated to be provided in the workplace, designed to enhance the skills of
within days or months. staff members or teach them new skills relevant to their jobs
and disciplines.
Governance – refers to the individual(s), group or agency
that have ultimate authority and responsibility for Palliative Services – are treatments and support services
establishing policy, maintaining quality of care, and intended to alleviate pain and suffering rather than to cure
providing for organization management and planning. Other illness.
names for this group include “board,” “board of trustees,”
board of governors,” “board of commissioners,” and Patient Record/Clinical Record – is a written account of a
“governing body.” variety of patient health information, such as assessment
findings, treatment details, progress notes and discharge
Health Care Organization – is a generic term used to summary. This record is created by nurses, physicians and
describe many types of organizations that provide health other health care professionals involved in the care of
care services. This includes ambulatory care centers, patients.
behavioral/mental health institutions, home care
organizations, hospitals, laboratories and long term Plan of Care – is a plan that identifies the patient’s care
organizations. It is also known as a “health care institution.” needs, lists the strategy to meet those needs, documents
treatment goals and objectives, outlines the criteria for
Health Care Professional – is any person who has ending intervention, and documents the individual’s progress
completed a course of study and is skilled in a field of in meeting specified goals and objectives. It is based on data
health. This includes a physician, dentist, nurse, or allied gathered during patient assessment. The format of the plan
health professionals. Health care professionals are often in some organizations may be guided by specific policies
licensed by a government agency or certified by a and procedures, protocols, practice guidelines, clinical paths
professional organization. or a combination of these. The plan of care may include
prevention, care, treatment, habilitation, and rehabilitation.
Indicator – is a measure of the performance of functions,
systems, or process, over time. Qualified Individual – is an individual or staff member who
can participate in one or all of the organization’s care
Informed Consent – is an agreement or permission activities or services. Qualification is determined by the
accompanied by full information on the nature, risks, and following: education, training, experience, competence,
alternatives of a medical procedure or treatment before the applicable licensure, law or regulation, registration, or
Quality of Care – is the degree to which health services for REFERENCES
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Standard – is a statement that defines the performance
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