STANDARDS OF

NURSING SERVICES

Association of Nursing Service Administrators

of the Philippines, Inc.
(ANSAP)
Committee on Nursing Practice
2008 Edition

STANDARDS OF
NURSING 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.

FOREWORD
This publication is designed to provide nursing
administration a guide reference in managing nursing services.
It also reflects the ANSAPs deep commitment in improving the
quality of patient care and management of nursing services in the
Philippines.
The development was actively participated by the Board
of Nursing (PRC-BON) and the ANSAPs Board of Directors
and validated by the Chief Nurses/Nursing Directors who are
also members of ANSAP.
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 ANSAP and the
international accrediting body like Joint Commission
International (JCI).

TABLE OF CONTENTS

Introduction
Clinical Services
I.

Standards on Assessment of Care

Standard I.
Assessment Process
Standard II.

Assessment Scope and Content

II.

Standards on Care of Patient

Standard I.
Care Process
Standard II.
Care Plan
Standard III.
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

III.

Standards on Patient and Family Education

Standard I.
Education Assessment
Standard II.
Education Plan and Programs

IV.

Standards on Access and Continuity of Care

Standard I.
Access to Care
Standard II.
Emergency Patients
Standard III.
Admitted Patients or In-Patients
Standard IV.
Intensive and Specialized Services

We view that standards are continuously a work in

progress. Hence, we welcome any comments and suggestions
for improvement.

Standard V.
Standard VI.
Standard VII.
V.

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

I.

II.

Standards on Governance and Direction

Standard I.
Governance Structure
Standard II.
Governance Responsibility and Accountability
Standard III.
Direction-Setting
Standard IV.
Strategic and Operational Plans
Standard V.
Financial Plan and Resource Allocation
Standard VI.
Policies and Procedures Development
Standard VII.
Ethico Moral and Legal Accountabilities
Standard VIII. Professional and Organizational Involvement
Standards on Human Resource Management
Standard I.
Administrator of Nursing Services
Standard II.
Staffing Plan
Standard III.
Recruitments, Selection, Hiring and Appointment
Standard IV.
Credentialing
Standard V.
Staff Placement
Standard VI.
Staff Job Description
Standard V.
Staff Development

III.

Standards on Facility Management and Environment

Safety
Standard I.
Facility Planning
Standard II.
Environmental Safety
Standard III.
Staff Education

IV.

Standards on Communication Management

Standard I.
Communication of Information
Standard II.
Patient Clinical Record
Standard III.
Administrative Record

V.

Standards on Quality Improvement

Standard I.
Leadership and Staff Education
Standard II.
Quality Programs
Standard III.
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:

I.

Standards on Assessment of Care. Classified

under are two criteria which include the process and
scope and content of assessment.

II.

Standards on Care of Patient. There are seven (7)

identified criteria that identify care process, care
plan, implementation of care and evaluation of care
rendered.
Included also is the medication
management and the family rights.

III.

Standards on Patient and Family Education has

two criteria in which the nurses independent role in
providing health education is hereby identified.

IV.

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.

V.

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.

The second part is the Administration and Management.

This concerns managing the nursing services in the hospital.
There are five (5) standards identified:

I.

Standards on Governance and Direction. 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.

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
services.

III.

Standards on Facility Management and

Environmental Safety.
This standard contains
three (3) criteria and covers environmental safety

IV.

V.

needed in the delivery of nursing services and

training of personnel to effectively carry out their
respective roles.
Standards on Communication Management.
Three (3) criteria are identified focusing on the
patients 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.

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
I.

Standards on Assessment of Care

Standard I: Assessment Process

3. Those responsible for direct nursing care collaborate

with medical and allied staff to analyze and integrate
the patients 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
encourage participation of the latter in the decisionmaking about the priority needs to be met.
Standard II: Assessment Scope & Content

The nurse identifies the health care needs of each patient

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

The scope and content of nursing assessment are well

defined in an institutional policy wherein those elements
common to all assessments and any differences with other
health disciplines are identified.

Measurable Elements

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 patients condition or
institutional policy.
1.2.1st 2 hours of consultation as an outpatient or
earlier as indicated by patients condition or
institutional policy.
2. There is an evidence of patients reassessment
throughout the care process to determine response to
intervention at interval appropriate to patients
condition, plan of care, individual needs or
according to institutional policies and procedures
(e.g. Pain is assessed every 4 hours and as necessary
as part of the vital signs monitoring).

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
Intergumentary 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 pediatrics)
Family history
Medications taken
Allergies
1.7. Vital signs
1.8. Pain assessment
1.9. Nutritional status, needs and risks
1.10.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
2.6. 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 patients 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:
5.1. 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 I: 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.

1.4.

1.5.
1.6.
1.7.
1.8.
1.9.
1.10.
1.11.
1.12.
1.13.
1.14.
1.15.

Care of emergency patients (including use

of resuscitation equipment)
Care of patient on life support (e.g.
ventilatory equipment)
Care of patient on dialysis (hemodialysis,
peritoneal dialysis)
Care of patients at risk:
Critically-ill
Neonates
Mentally disadvantaged
Children
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
Care of patient in pain
Care of patient on nutritional therapy
Care of patient receiving blood and blood
components
Care of patient receiving medications with
narrow margin of safety
Care of perioperative patient
Care of patient with intravenous therapy

Standard II: Care Plan

The nurse caring for patients develops and updates an
individualized written care plan in the patients record within
the prescribed time frame.
Measurable Elements

1. There is a written care plan on every patient cared of

2.

3.
4.
5.
6.

by the nurse based on patients 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
patients record to promote continuity of care.

Standard III: 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:

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)

1.2. Standard of Care:

Acute and Critical Care Nursing Practice
Chronic Care Nursing Practice
Cardiovascular Nursing Practice
Perioperative Nursing Practice
Maternal and Child Nursing Practice
Psychiatric Nursing Practice
Emergency Nursing Practice
Renal Nursing Practice
Pediatric Nursing Practice
Oncology Nursing Practice
Geriatric Nursing Practice
Ethical and Legal Nursing Practice
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 of 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 IV: Evaluation of Care

The nurse caring for patients systematically and

continuously evaluates the patients progress based on the
effectiveness of nursing intervention rendered and medical
management provided.

Measurable Elements
1.

Systematic and continuous evaluation of patients

progress and effectiveness of care is reflected in the
individualized patient record.
2. There is an evidence that evaluation of care and
patient outcome occurs within an appropriate time
frame after the intervention (nursing or medical) is
initiated.
3. There is an evidence that patients responses to
interventions are documented.
4. 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

Standard VII: End-of-Life Care

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.

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 diversities in beliefs and
customs and optimize caring environment.

Measurable Elements

Measurable Elements

1. There are written policies, procedures and guidelines

on medication management which include but are
not limited on the following:
1.1. Carrying out physicians medication order
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

1. Respect for patients 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 patients 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.
2. Assessment, appropriate intervention to alleviate the
patients pain and discomfort according to wishes of
patient and family and re-assessment are evident.
2.1. Pain assessment, intervention and
evaluation, are monitored and recorded.
2.2. Personal hygiene is rendered based on patients
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
familys psychosocial, emotional, spiritual and
cultural
concerns.
3. A place is designated for the patients family to stay.
4. The patient and family are involved in care
management and decision.

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.

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 patients personal values and beliefs
1.3. Respect the confidentiality of patient health
information
1.4. Respect for patients need for privacy (e.g.
during
treatment,
procedure,
physical
examination, clinical interview, transport)
1.5. Protection of patients possessions from theft
or loss
1.6. Protection of patient from physical assault
(e.g. vulnerable patients are infants, children
and
elderly)

III.

Standards on Patient and Family Education

Standard I: Education Assessment
The nurse assesses the educational needs of each patient
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. Patients and familys beliefs and values
1.2. Patients and familys literacy
1.3. Patients and familys educational level

1.4. Patients and familys language

1.5. Patients and familys motivations
and emotional barriers
1.6. Patients physical and cognitive limitation
1.7. Patients 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 patient and

family are evident according to the type of patient
served and his/her learning needs.
2. The appropriate structure, methods and mechanism
for education is afforded.
3. Education resources are available and organized in
an efficient and effective manner.
4. When appropriate, it is evident that the patient and
family are educated on topics considered high risk to
patients:
4.1. Safe and effective use of medications and their
side effects
4.2. Preventing interactions between prescribed
medications and other medications (over the
counter) and food
4.3. Safe and effective use of medical equipment
4.4. Pain management
4.5. Rehabilitation techniques
4.6. Treatment and diagnostic procedures

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 communication skills to do so.
IV.

Standards on Access and Continuity of Care

Standard I: 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 triaging 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, prioritized and received the
necessary care as quickly as possible according to
established physiologically based criteria.
2. There is an evidence that staff who responded to
emergency patients underwent the necessary
training.
Standard III: 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 prioritized 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 prioritizes these according to
the patients 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 are not limited on the following:

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 overcome barriers such as language,
cultural, physical, to access and in the delivery
of care
Standard IV: 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
non- surgical 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 patients discharge,
out on pass, referral and follow-up congruent with those of
the organization.

2. There are criteria that determine patients readiness to

be discharged.
3. 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 patients discharge summary is prepared by
qualified individuals recognized by the organization.
6. A copy of patients discharge summary is placed in
the patient record and another copy is given to the
patient which include but are not limited on the
following:
6.1. Reason for admission
6.2. Significant physical and other findings
6.3. Significant diagnosis and co-morbidities
6.4. Diagnostic
and
therapeutic
procedures
performed
6.5. Medications and treatments
6.6. Medications to be taken at home
6.7. Condition of patient at the time of discharge
6.8. Follow-up instruction in an understandable form
and manner
Activity
Diet
Next medical consultation
Urgent care indicators
6.9. Referral for support services to either health care
providers, health organizations or agency, and
health professionals in the community.
Standard VII: Transfer of Patient

Measurable Elements
1. There are written policies, procedures and guidelines
on patients discharge, out on pass, referral and
follow-up congruent with those of the organization.

The Nursing Services Department has established

policies, procedures and guidelines regarding the transfer of
patient within and outside of the organization.

Measurable Elements
1. There is a written policy, procedure and guidelines
on transfer of patient within and outside of the
organization.
2. The guidelines and procedures include but are not
limited on the following:
2.1. Transfer is based on the patients needs for
continuity of care.
2.2. Transfer
of
responsibility to
another
health provider or health care setting is evident.
2.3. Responsible health care provider during the
patients transfer is identified.
2.4. Formal and informal arrangements are apparent.
2.5. Summary
of
patients
clinical
condition, interventions (medical and nursing)
and continuous care rendered are written.
2.6. Situation when transfer is not possible is stated.
2.7. Patients transfer is documented.
2.8. Safe and quality medical transport services
within and outside of the organization are
provided.
V.

Standards on Nursing Documentation

Standard I: Structural Data
The nurse documents structural data of each patient
accurately and completely based on applicable laws and
regulations, professional standards and institutional
requirements.
Measurable Elements
1.

There is an accurate and complete documentation

of patients structural data in all nursing and

applicable forms which include but are not limited

on the following:
1.1.
Patients addressograph name, age,
gender, civil status
1.2.
Registration number and or Admission
number
1.3.
Date and time of admission and discharge
1.4.
Mode of admission/transport/discharge
1.4.1. Admitted
via:
ambulatory,
wheelchair, stretcher
1.4.2. Admitted from: home, transferring
hospital, care facility
1.5.
Attending physician and referring physician,
if any
1.6.
Religion
1.7.
Language spoken
1.8.
Advance directive
1.9.
Health Care Insurance
Standard II: Clinical Data
The nurse documents essential clinical data of each
patient accurately and completely based on individualized
nursing care plan from admission to discharge in health care
facility.
Measurable Elements
1.

There is relevant/essential, accurate and complete

nursing documentation of patients clinical data in
all appropriate forms from admission to discharge
in health care facility which include but are not
limited on the following:
1.1.
Physical examination (head-to-toe)
1.2.
Health history

1.3.
1.4.
1.5.
1.6.
1.7.
1.8.
1.9.
1.10.

Psychological,
social,
spiritual
and
economic evaluation
Actual and potential health problems and
needs
Diagnostic and therapeutic interventions
Pharmacological management
Nursing interventions
Health teachings patient and family
Patients response and outcome
Preferences and idiosyncrasies

ADMINISTRATION & MANAGEMENT

I.

Standards on Governance and Direction

Standard I: Governance Structure
The Nursing Services Department has governance
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 decisionmaking 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
development.
Standard

II:

Governance
Responsibility
Accountability

and

The governance responsibility and accountability are

described in a written document to guide how they are to be
carried out.
Measurable Elements

time bound, ethical and recorded), reviewed,

updated, widely disseminated, interpreted and
operationalized.
Standard IV: Strategic & Operational Plans

1. The governance responsibility and accountability are

described in organizations by-laws, job description
and other similar documents.
2. Those responsible and accountable for governing
and managing the Nursing Services Department are
identified by position title and name.
3. Those responsible for governance appoint the
Nursing
Services
Administrator,
managers,
professional technical staff and assistive nursing
personnel to carry out the functions of the Nursing
Services Department.
4. There is a written document that describes how the
performances of the governing entity are appraised
by specific criteria.

The Nursing Services Department has documented

strategic and operational plans consistent with the hospital
wide quality plan.

Standard III: Direction-Setting

The Nursing Services Department has an established
vision, mission, philosophy, core values and quality
objectives congruent with that of the institution and the
Nursing profession.
Measurable Elements
1. Those responsible for the Nursing Services
Department governance, primarily sets its direction
by formulating its vision, mission, philosophy, core
values and quality objectives congruent with that of
the institution and the Nursing profession.
2. The vision, mission, philosophy and core values are
written (specific, measurable, attainable, reliable,

Measurable Elements
1. Those responsible for governance forecast and direct
the future and operation of the Nursing Services
Department in order to achieve its overall goals.
2. There is an existence of strategic and operational
plans periodically set and reviewed which contains
goals and objectives, action plan/activities,
timeframe, resources required and contingencies.
3. Those in the managerial and clinical levels translate
the overall Nursing Services Department strategic
and management plans into action which include:
the management of patient care, nursing manpower
and unit operation of responsibility areas.
Standard V: Financial Plan & Resource Allocation
The Nursing Services Department has financial plan and
allocation of resources required to meet its goals and sustain
its operation.
Measurable Elements
1.

Those responsible for governance have established

current financial plans and allocation of resources
based on the needs of the Nursing Services
Department.

2. The capital and operating budgets are implemented

as approved by the authorized person/office and
monitored based on responsibility accounting.
3. Each Nursing Unit has an individual budget plan
periodically monitored for variances.
4. The medical supplies, materials and equipment
recommended by professional organizations and
authoritative sources are obtained and appropriately
used.
Standard VI: Policies & Procedures Development
The policies and procedures of the Nursing Services
Department
that
reflect
Standards
of
Nursing
Administration, Nursing Practice on Patient Care are
developed and communicated to serve as operational
guidelines.

conforms with the applicable statutory laws, rules and

regulations.
Measurable Elements
1. Those responsible for governance formulate policies
and procedures to serve as guidelines for those
confronted by ethico-moral dilemmas in patient care.
2. Those responsible for governance ensure compliance
with the applicable statutory laws, regulations and
standards.
3. The Nursing Services Department has a written
Code of Ethical Behavior which observes the rights
and safety of patients and health care providers.
Standard
Involvement

VIII:

Professional

&

Organizational

Measurable Elements
1. Those responsible for governance develop and
implement policies and procedures based on
established Standards of Nursing Administration and
Nursing Service on Patient Care.
2. An updated manual of Nursing Services policies and
procedures exists and provides clear directive for
nursing personnel at different levels on the scope
and limitations of their functions and responsibilities
to patient care.
Standard VII: Ethico Moral & Legal Accountabilities
The Nursing Services Department has an established
framework for ethico-moral and legal management to
support the ethical decision-making in the clinical areas, and

The administrator of the Nursing Services Department

actively participates and collaborates with leaders within the
organization and professional associations for continuous
quality improvement of nursing services.
Measurable Elements
1.

Those responsible for Nursing Services Department

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

1.1.4.
II.

Standards on Human Resource Management

Standard I: Administrator of Nursing Services
The Nursing Services Department is administered by a
qualified nursing administrator pertinent to licensure,
appropriate education, experience and demonstrable proven
ability in nursing practice and administration, fully
responsible and accountable for the operation of the entire
Nursing Services of the organization/institution.
Measurable Elements
1.

There are presence of evidences that the Nursing

Service Administrator is qualified to the position
based on RA 9173 and other criteria set by the
organization/institution such as:
1.1 Qualifications
of
Nursing
Service
Administrators:
A person occupying supervisory or
managerial positions requiring knowledge of
nursing must:
1.1.1. Be a registered nurse in the
Philippines;
1.1.2. Have at least two (2) years experience
in
general
nursing
service
administration;
1.1.3. Possess a degree of bachelor of
Science in Nursing, with a least nine
(9) units in management and

administration courses at the graduate

level; and
Be a member of good standing of the
accredited professional organization
of nurses.

1.2. A person occupying the position of chief nurse

of director of nursing service shall, in addition
to the foregoing qualifications, possess:
1.1.1.
At least five (5) years of experience
in a supervisory or management
position in nursing; and
1.1.2.
A masters degree major in nursing.
1.3. That for primary hospitals, the maximum
academic qualifications and experiences for a
chief nurse shall be as specified in subsections
(1.1.1), (1.1.2.), and (1.1.3) of the above.
1.4. That for chief nurses in the public health
agencies; those who have a masters degree in
public health/community health nursing shall
be given priority.
1.5. That for chief nurses in military hospitals,
priority shall be given to those who have
finished a masters degree in nursing and the
completion of the General Staff Course
(GSC).
2.
Those responsible for the overall administration
and management of Nursing Services is a member
of the top Executive/Management Committee who
participates in their regular meetings and provides
advice and recommendations in relation to nursing
practice.
Standard II: Staffing Plan

The Nursing Services Department has a staffing plan

that identify the number, type and desired qualification of
nursing services staff which is written, reviewed and updated
on an ongoing basis.

Measurable Elements
1.

Those responsible for Nursing Services governance

develop a staffing plan that identify the number, type
and desired qualification (education, skills and
experience) of Nursing Services staff, reviewed and
updated on an ongoing basis.
2. Those responsible for Nursing Services governance
consider the organizations mission, type of services,
level and modality of care, patients mix, staff and
skills mix and other factors affecting the projection
of staffing needs.
3. The staffing plan is defined in writing and meets the
needs of the patients/population served and scope of
services.
Standard III: Recruitment, Selection, Hiring and
Appointment
The Nursing Services Department has an established
system and processes for recruitment, selection, hiring,
appointment and promotion of human resources in
accordance with the statutory laws and regulations and the
institutional policies and procedures.
Measurable Elements
1. Those responsible for the Nursing Services
governance actively participate/collaborate in the

development of system and processes for

recruitment, selection, hiring, appointment and
promotion of nursing service personnel in
accordance with 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
personnel and are uniformly implemented.
3. Staff recruitment, selection, hiring and appointment
are based on institutional, patients needs and
applicant qualification.
Standard IV: Credentialing
The Nursing Services Department has an effective
process for gathering, verifying and evaluating the nursing
staff credentials.
Measurable Elements
1.

Those responsible for Nursing Services governance

develop an effective process for gathering, verifying
and evaluating the nursing staff credentials
(licensure, education, training, work experience) and
other pertinent requirements.
2. There is evidence of standardized procedure to
gather the credentials of all nursing staff.
3. The licensure, education, training and work
experiences of nursing personnel are documented
and updated.
Standard V: Staff Placement
The Nursing Services Department has defined criteria
and processes to ensure the clinical staff knowledge and
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
develop and define the criteria (core competencies)
and processes to match the clinical staff knowledge
and skills with the patients needs.
2. There are written core competencies required for
every job position in the Nursing Services
organization to ensure that the staff skills are
consistent with the patients needs.
3. Staff placement/assignment is based on patient
needs, available resources and staff competencies.
Standard VI: Staff Job Description
The Nursing Services Department has job description for
each position classification of Nursing personnel, which
specifies duties and responsibilities based on established
standards of performance.
Measurable Elements
1.

There is a written Job Description for each position

classification of Nursing Services personnel which
specifies:
1.1.
Duties and responsibilities
1.2.
Accountability
1.3.
Functional relationship
1.4.
Qualification and experience required

Standard VII: Staff Development

The Nursing Services Department has an established
staff development program for all nursing personnel to
encourage and promote continuing personal and professional
growth and development.
Measurable Elements
1.

Those responsible for Nursing Services governance

design and implement staff development programs
for nursing personnel at all levels based on training
needs analyses.
2. There is evidence of staff development programs for
all nursing personnel throughout the year which
include:
a. Orientation program for newly hired and
promoted
staff,
to
the
organization
department/unit to which they are assigned as
well as their specific job responsibilities.
b. Safety program to protect the patient, staff and
property.
c. Continuing education, training and opportunities
for professional advancement of staff member to
enhance their knowledge and skills.
d. Career
counseling
and
career
advancement/ladder.
3. Resources are available to implement the staff
development program such as:

3.1. Space and facilities

3.2. Educational resources
3.3. Clinical and clerical staff
3.4. Audiovisual equipment
3.5. Resource speakers
4. Policies and procedures on continuing education
staff attendance to staff development programs are
evident.
5. Records of staff development program are
maintained which include:
5.1.
Title of the program
5.2.
Objectives of the program
5.3.
Program design and content
5.4.
Evaluation of the attendees
5.5.
Effectiveness of the program
5.6.
List of attendees/participants
III.

Standards on Facility Management & Environment

Safety
Standard I: Facility Planning
For efficient and effective delivery of nursing care and
services, the Nursing Services Department provides a safe,
functional and supportive facility to patients and their
families, staff and visitors aligned with that of the
organizations master plan.
Measurable Elements
1. Those responsible for governance comply with
relevant laws, regulations and other requirements
that are applicable.

2. Those responsible for governance actively

participate in space planning as well as medical
equipment and supplies procurement.
3. Those responsible for governance, plan and budget
for upgrading or replacing key components based on
facility inspection findings.
Standard II: Environmental Safety
The Nursing Services Department actively participates
in the planning, implementation and evaluation of hospital
wide programs to provide a safe and secure physical
environment.
Measurable Elements
1. There is a written and up-to-date plan,
implementation
and
evaluation
of
programs/activities to manage the risks within the
environment which includes but is not limited on the
following:
1.1. Safety and Security
There is an existing provision for the
identification of patient and their families,
visitors, staff and others.
Monitoring mechanism of all risk areas is
in place and kept secure to patient from
unauthorized access or use, tampering,
destruction or loss. (e.g. Medication
Room)
1.2. Hazardous Materials and Waste
There is a current list of hazardous
materials and waste to safely control them
(e.g. chemotherapeutic agents, chemicals,
radio-active
materials
and
waste,

hazardous gases and vapors, infectious

waste).
There is an existing written processes on
handing, labeling, storage, use, inventory
and disposal of hazardous materials and
waste.
Documentation and reporting system are
in place for investigation of spills,
exposures and other accidents related to
hazardous materials and wastes.
1.3. Medical Equipment
There is an updated policy and processes
on medical equipment procurement,
inventory, regular inspection, preventive
maintenance, and recall system.
Monitoring of equipment functionality and
utilization is in place for purposes of
planning and improvement.
1.4. Utilities
Potable water, electrical power, and
medical gases are available 24 hours a
day, seven (7) days a week.
A written emergency processes is in place
in the event of water interruption or
contamination, electrical failure or
interruption
and
medical
gases
unavailability.
Monitoring of utilities is evident for
purposes of planning and improvement.
1.5. Emergencies
An emergency management plan and
processes are evident to likely community/

institutional emergencies, epidemics, and

disasters.

1.6. Fire Safety

There is an evidence that fire safety plan
and
program
of
the
organization/institution is implemented in
a continuous and comprehensive manner
to all patient care and staff work areas.
1.7. Infection Control
There is evidence that policies, procedures
and guidelines on infection control are
implemented.
There
are
infection
surveillance,
prevention and control programs to
identify and reduce the risks of acquiring
and transmitting infections among patients
and nursing staff.
There is evidence that the nursing staff is
provided with education on infection
control practices.
Standard III: Staff Education
The Nursing Services Department ensures education and
training of staff to effectively carry out their roles in creating
a safe and sound patient and staff environment.
Measurable Elements

1. There is an evidence of staff education and training

on facility management and environmental safety
programs.
2. There is an evidence that the staff can describe and
demonstrate their role in the aforementioned safety
programs.
3. There is an evidence of staff training to operate
medical equipment appropriate to their job
description.
VI. Standards on Communication Management
Standard I: Communication of Information
The Nursing Services Department has efficient and
effective system of communication with the community, to
patients and their families, nursing personnel and other
health professionals throughout the organization.
Measurable Elements
1. There is efficient and effective system of
communication that exist which include but are not
limited on the following:
1.1. Community
Patient/nursing care services
Health programs
Process to access care
1.2. Patients and Families
Patient health condition
Care provided to patient
Patients response to care
Patient/nursing care services available
Alternative sources of care and services
Process to access care

Educational materials and methods in an

understandable format and language
1.3. Nursing Personnel
Nursing endorsement in between work
shifts
Nursing documentation
Referral
Nursing Service Philosophy, Vision,
Mission, Core Values
Policies,
Procedures,
Guidelines,
Standards
Memorandum,
Circular,
Directives,
Activities
1.4. Other Health Professionals (clinical and nonclinical staff)
Patient care and response to care (referral)
Patient
clinical
data
(diagnostic
examinations and therapeutic procedures)
Circular
Standard II: Patient Clinical Record
The Nursing Services Department has established
policies, procedures and guidelines on patient clinical record.
Measurable Elements
1. There are written policies, procedures, and
guidelines on patient clinical record which include
but are not limited on the following:
1.1. Clinical record for every patient assessed
or treated, in-patient or out-patient
1.2. Confidentiality of record
1.3. Security of record

Protection from loss and destruction and

unauthorized access and use
1.4. Data Integrity
Protection from tampering
1.5. Use
and
monitoring
of
standardized
abbreviations, symbols, procedure codes and
definitions
1.6. Retention period of records (as prescribed
by law and institutional policy)
Standard III: Administrative Record
The Nursing Services Department has established
policies or protocol in keeping and maintaining its
administrative record and defining the requirements for
developing and maintaining policies and procedures.
Measurable Elements
1.

There is a written policy or protocol in keeping and

maintaining
Nursing
Services
Department
administrative records which include but are not
limited on the following:
1.1. Organization and Nursing Services Department
Policies, Procedures, Guidelines
1.2. Standards
1.3. Master Staffing Plan
1.4. Staffing Pattern
1.5. Census of Patients and Diseases
1.6. Bed Capacity and Occupancy Rate
1.7. Budget Plan
1.8. Staff Development Programs
1.9. Committees, Nursing and the Organization
1.10.Minutes of Meeting, Nursing Services
Department

1.11.Quality Improvement Program and other

Projects
1.12.Manuals of the Organization
Quality System
Infection Control
Emergency Preparedness
Employees Manual
Others
2. There is written policy or protocol in developing and
maintaining policies and procedure which include
but are not limited on the following:
2.1. Review and approval of all policies and
procedures before implementation
2.2. Process and frequency of review and continued
approval of policies and procedures
2.3. Control that only current policy and procedures
are implemented
2.4. Identification of charges in policy and
procedures
2.5. Retention of obsolete policies and procedures
2.6. References originating outside the organization
2.7. Tracking of policy and procedures in circulation
(e.g. title, date of issue, authorized person)
V. Standards on Quality Improvement
Standard I: Leadership and Staff Education
The Nursing Services Department has continuous quality
improvement on patient and staff safety programs through
monitoring and analyzing variation of data and undesirable
trends of events.
Measurable Elements

1.

2.

3.
4.
5.
6.

Those responsible for governing and managing the

Nursing Service Department lead or actively
participate in planning, monitoring, analyzing and
implementing quality improvement and patient and
staff safety programs congruent with the
organizational needs.
There is an evidence that information on quality
improvement and patient and staff safety programs
are communicated to staff on a regular basis through
effective channels inclusive of progress on
compliance.
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 training
and staff participation as part of their regular work
assignment.
There is an established reporting system on the
quality and safety programs to governance.
Those in governance support and take action on
recommendation for quality improvement and
patient and staff safety programs based on the result
of root cause analysis.

Standard II: Quality Programs

The Nursing Services Department has priority quality
programs to reduce high volume, high risk and problemprone processes.
Measurable Elements
1. There is written plan or policy or document of a well
designed new processes or modified existing
processes consistent with current practice,
guidelines, clinical standards, scientific literature,

and other relevant evidence based information.

(e.g. Medication safety, clinical pathway)
2. There is an existing plan and program to reduce the
risk of community/hospital acquired infectious for
patients and health care associated infections for
staff.
3. There is an evidence that the quality
improvement/processes and safety programs are
approved by governance, implemented and
monitored for consistent use and effectiveness.
Standard III: Quality Monitoring, Analysis &
Implementation
The Nursing Services Department has established key
indicators to monitor the clinical and managerial structure,
processes and results and data are aggregated, analyzed and
transformed to useful information.
Measurable Elements
1. There is a clinical monitoring that exists but is not
limited on the following:
1.1. Clinical research
1.2. Nursing documentation
1.3. Medication error
1.4. Intravenous fluids
1.5. Blood and blood products
1.6. Total parenteral nutrition
1.7. Surgical safety (sterilization/disinfection)
1.8. Infection control, surveillance, reporting
(needle stick injury, hand hygiene and barrier
technique,
body
fluids
and
waste
segregation/disposal)
1.9. Prevention and control measures aligned with
International Patient Safety Goals. (Isolation
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, if any
2.3. Availability of drugs and medical supplies
essential to most patient needs (e.g. Emergency
Kart contents)
2.4. Financial budget
2.5. Manpower utilization
2.6. Staff expectations and satisfaction
2.7. Incident reports and sentinel events
2.8. Reports as required by law and regulation and
those in governance
3. There is an evidence data analysis and actions taken.
4. There is an evidence that actions for improvement
are appropriate to the care, scope and severity of the
problems.
5. There is an evidence that the actions for
improvement or changes are planned, tested and
implemented.
6. There is a written available data to demonstrate that
the improvements are effective and sustained.

GLOSSARY
Adverse Event is an unanticipated or potentially
dangerous occurrence in health care organization.
Clinical Pathways is an agreed-upon treatment regime
that includes elements of care.
Communication Management is the creation, use,
sharing and disposal of data or information for effective and
efficient operation of organization activities. It includes the
role of management to produce and control the use of data
and information in work activities, information resources
management, information technology, and information
services.
Continuity of Care is the matching of an individuals
ongoing needs with the appropriate care setting; level of
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 patients condition on discharge, and other specific

instructions given to the patient or family (for example,

follow up, medications).
End-of-Life Care is the provision of care to the patient
whose disease condition is not responsive to curative
treatment, and his/her life expectancy is estimated to be
within days or months.
Governance refers to the individual(s), group or agency
that have ultimate authority and responsibility for
establishing policy, maintaining quality of care, and
providing for organization management and planning. Other
names for this group include board, board of trustees,
board of governors, board of commissioners, and
governing body.
Health Care Organization is a generic term used to
describe many types of organizations that provide health
care services. This includes ambulatory care centers,
behavioral/mental
health
institutions,
home
care
organizations, hospitals, laboratories and long term
organizations. It is also known as a health care institution.
Health Care Professional is any person who has
completed a course of study and is skilled in a field of
health. This includes a physician, dentist, nurse, or allied
health professionals. Health care professionals are often
licensed by a government agency or certified by a
professional organization.
Indicator is a measure of the performance of functions,
systems, or process, over time.
Informed Consent is an agreement or permission
accompanied by full information on the nature, risks, and
alternatives of a medical procedure or treatment before the

physician or other health care professional begins the

procedure or treatment.
In-Service Education is an organized education, usually
provided in the workplace, designed to enhance the skills of
staff members or teach them new skills relevant to their jobs
and disciplines.
Palliative Services are treatments and support services
intended to alleviate pain and suffering rather than to cure
illness.
Patient Record/Clinical Record is a written account of a
variety of patient health information, such as assessment
findings, treatment details, progress notes and discharge
summary. This record is created by nurses, physicians and
other health care professionals involved in the care of
patients.
Plan of Care is a plan that identifies the patients care
needs, lists the strategy to meet those needs, documents
treatment goals and objectives, outlines the criteria for
ending intervention, and documents the individuals progress
in meeting specified goals and objectives. It is based on data
gathered during patient assessment. The format of the plan
in some organizations may be guided by specific policies
and procedures, protocols, practice guidelines, clinical paths
or a combination of these. The plan of care may include
prevention, care, treatment, habilitation, and rehabilitation.
Qualified Individual is an individual or staff member who
can participate in one or all of the organizations care
activities or services. Qualification is determined by the
following: education, training, experience, competence,
applicable licensure, law or regulation, registration, or
certification.

Quality of Care is the degree to which health services for

individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge.
Safety is the degree to which the risk of an intervention
and risk in the care environment are reduced for a patient
and other persons, including health care providers.
Standard is a statement that defines the performance
expectations, structures, or process that must be in place for
an organization to provide safe and high-quality care,
treatment, and service.
Standard of Nursing Practice is an authoritative
statements that describe the responsibilities for which
nursing practitioners are accountable.
Outcome Standards Describes the basis level of care the
patient can expect to receive.

REFERENCES
Association of Nursing Service Administrators of
Philippines, Inc. (2001) Standards of Nursing Services

the

Association of Nursing Service Administrators of the

Philippines, Inc. and Philippine Nurses Association, Inc.
(1999). Standards of Safe Nursing Practice
Committee on the Revision of the Hospital Nursing Service
Administrative Manual (1990).
The Administration of
Hospital Nursing Services in Philippine Department of
Health, 1st Edition
Joint Commission International (2008). Accreditation Standards
for Hospitals, 3rd Edition Printed in USA 54321
Joint Commission International (2004). Credentialing, Edition
Printed in USA 54321
Joint Commission International (2004). Human Resources for
Hospitals, Edition Printed in USA 54321
Noe, Hollenback, Gerhart, Wright (2004).
Fundamental of
Human Resource Management, McGraw-Hill Co. Inc. New
York
Republic Act 9173 or The Philippine Nursing Act of 1991,
Republic of the Philippines, Metro Manila
Robbins, S. Coulter M (2004). Management, 7th Edition,
Pearson Education South Asia PTE LTD.

Rowland H & Rowland B (1980).

Handbook, Aspen Publication

Nursing Administration

Tomey A.M (2004). Guide to Nursing Management and

Leadership, 7th Edition
Weber, J (2006). Nurses Handbook of Health Assessment, 5 th
Edition, Lippincott Williams & Wilkins