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First Edition
October 2013
Nursing services are an integral part of the clinical services of any health care
organization. The aim of nursing services is to provide comprehensive nursing care in
terms of health promotion, prevention of diseases and therapeutic nursing care to the
patients in a HCO as well as to the community. The objective of the nursing professional
is to provide safe, competent and ethical nursing care with compassion, comfort and
collaboration with the patients, the family, the community and the clinical care team. The
Nursing professionals are the cornerstone of any quality related programme in a health
care organization since most of the delivery and monitoring of health care is carried out
by them. The nursing professionals are the frontline staff with whom the patients, their
families and the visitors interact first hand. Their knowledge, skills, attitude,
communication and other soft skills thus make all the difference in the ultimate delivery
of health care to the patients.
Standards are pre requisite for the promotion of safe, effective, competent and ethical
nursing care. They help the individual nursing practitioner to evaluate the services being
provided by them and also act as a catalyst for self regulation and improvement.
Nursing excellence standards have been framed with a view to lay down the guidelines
for evaluating the nursing services being provided by a Health Care Organization,
thereby providing a platform for continual improvement. These standards are applicable
to all the Health care organizations irrespective of their size, role and complexity. They
will help in regulating, guiding and promoting professional nursing practice. They will
serve as guidelines to nurse administrators and supervisors for supporting and
facilitating safe, competent and ethical nursing practices within their Health Care
Organizations.
Apart from serving as a frame work for evaluation of the quality of nursing services
rendered, these standards will also provide guidelines to assist nurses in decision-
making and will support the nursing efforts by outlining the professional expectations
2
from the nursing services. The Standards are on the same framework as has been for
the NABH Standards for Health Care Organizations.
The 1st edition of nursing excellence standards is divided into 07 chapters, focusing on
various professional, administrative and governance aspects of nursing. Seven chapters
are further divided into 48 standards. Put together there are 216 objective elements
incorporated within these standards. Objective elements are required to be complied
with in order to meet the requirement of a particular standard. Similarly, standards are
required to be complied with, in order to meet the requirement of a particular chapter.
Finally all chapters are deciding factor to say whether a hospital is meeting the
requirements of the certification program. In the beginning of each chapter, intent is
given to highlight the summary of the chapter. For most of the objective elements,
interpretation is provided just to further elaborate on how that objective element can be
met.
Standards are dynamic and would be under constant review process. Comments and
suggestions for improvement are appreciated. We seek your support in keeping these
standards adequate to the need of industry.
3
TABLE OF CONTENTS
4
CHAPTER 1
Nursing staff is the most important resource of a hospital and healthcare system. The
goal of nursing resource management is to acquire, provide, retain and maintain
competent staff nurse in right numbers to meet the needs of the patients and community
served by the organization.
Training and development of the nursing staff must be in consonance with the expected
performance in the present and future anticipated jobs. The nursing professionals shall
be provided with opportunities for professional advancement. The organization shall lay
down the job description and procedures for credentialing and privileging of the nursing
staff.
5
Summary of Standard
6
Standards and Objective Elements
Standard
7
care, treatment and the patients. Workload
service needs of the on Nursing professionals
patient. will be monitored.
c. The person heading the INC recognized Self-explanatory.
nursing service has qualifications with
requisite and appropriate management
qualifications. training/degree.
d. The person heading the Self-explanatory As per INC guidelines /
nursing service has MOHFW hospital
requisite and appropriate manual guidelines.
experience.
e. The required job The content of each job Refer to glossary for
specification and job should be well defined definition of "job
description are defined and the qualifications, description” and “job
for each category of skills and experience specification". For a job
nursing staff. required for performing which requires the skills
the job should be clearly of a nurse the minimum
laid down. The job qualification shall be a
description should be GNM/ B.Sc Nursing.
commensurate with the
qualification. This should be part of
nursing manual, refer
NCP 1.
Standard
NRM.2. The organization has structures and processes for induction and for
enhancing the transition of novices to competent nursing professionals.
8
a. Nursing shift plans based upon For eg. if the shift Self-explanatory.
timings of shift, day or week shall for a unit is eight
identify and depute nursing hourly then the
professionals to various areas nursing
based on their skills and professionals doing
competencies. the shift at night
should have skills
and competencies
that enable her to
independently
monitor and handle
emergency
situations.
b. Training need shall be identified Self-explanatory. Self-explanatory.
on a continual basis by the senior
nursing professionals as well as
the Clinical Heads as appropriate.
c. Required competency parameters These are generally Self-explanatory.
shall be evaluated by such senior bed-side nursing
nursing professionals and the care procedures
clinical and support service Heads and are therefore
and shall be recorded in the evaluated on a
training records as in NRM 2. continual basis. The
recording may be
done at suitable
periodic intervals.
Standard
NRM.3. The organization has processes in place for induction training, In-service
education and Continuous Nursing Education (CNE) programmes and for
9
documentation of the same in the personal files.
10
should be prepared.
c. The organization maintains The organization Where possible, the
records of training. shall maintain a contents of the
record of all training may also be
trainings provided. captured. Regular
At a minimum, it assessments of the
shall include the title effectiveness of the
of the training, the imparted training in
trainer(s), list of the respective work
trainees (with locations must be
signatures) and the carried out and
post-training records of the same
feedback. maintained.
d. Nursing professionals shall The training should
receive adequate training when focus on the revised
there is a change in job job responsibilities
responsibilities or when new as well as on the
equipment is introduced. newly introduced
equipment and
technology. In case
of new equipment,
the operating
nursing staff should
receive training on
operational as well
as daily-
maintenance
aspects.
e. All nursing staff shall be trained to Self-explanatory. Self-explanatory.
provide BLS. Nursing
professionals working in intensive
11
care/high dependency units shall
undergo training in ACLS or PALS
or NALS as applicable.
Standard
12
the law.
c. All such information pertaining to The organization Educational
the nursing staff is appropriately shall do the same parameters are
verified when possible. by verifying the validated by
credentials from the verifying the
organization which qualification
has awarded the certificates. Training
qualification/training. is validated through
training certificates
and skill verification
on the job and
experience is
validated by way of
the records
provided by the
nurse from the
previous employers.
d. Nursing staff are granted The organization For example, an
privileges in consonance with shall lay down Infection Control
their qualification, training, parameters for Nurse should have
experience and registration. identifying as to had requisite in-
what each nurse is house/external
authorised to do. training and
It is preferable to get experience and the
the privileging done aptitude and
through a knowledge to
credentialing and perform the tasks
privileging. To be required of her.
read in conjunction
with NRM 4b
committee based on
13
pre existing criteria /
parameters.
e. The requisite services to be Self-explanatory. This could be done
provided by the nursing staff are by internal
known to them as well as the communication.
various departments/units of the
organization.
f. Nursing professionals care for Self-explanatory. The organization
patients as per their privileging. New staff members could evolve a
Standard
NRM.5. An appraisal system for evaluating the performance of nursing staff exists
as an integral part of the nursing resource management process.
14
For definition of
“performance appraisal”
refer to glossary.
for identified
based on the pre- The for each
criteria
determined criteria. assessment should be nursing staff and training
defined and known to need assessment is also
the nursing done at the time of
professionals. It is assessment.
preferable to have
objective criteria that
can be supplemented
by subjective remarks.
d. Performance appraisal is Self-explanatory. This shall be done at
carried out at pre-defined least once a year.
intervals and is recorded.
Standard
15
a. Patients, families and staff shall Self-explanatory. Self-explanatory.
be encouraged to report positive
feedback about nursing care
delivered in relevant areas.
b. Nursing staff with managerial Self-explanatory. Self-explanatory.
responsibilities shall ensure that
soft skills in nursing, qualities of
leadership and professional
competence are duly reported to
higher authorities. This shall be
recorded (see NRM 4 c also).
Standard
16
procedure is based on the justice shall be
principles of natural justice. followed to ensure
that a nursing staff
against whom there
is a complaint, of
any sort, has the
right to explain
himself/herself.
Standard
17
workplace safety
from sexual
harassments.
d. A record of corrective and Self-explanatory. Self-explanatory..
preventive actions shall be
maintained wherever appropriate,
with due consideration given to
anonymity.
Standard
18
CHAPTER: 2
The standard aims to guide and encourage patient safety and quality care as the
overall principle for providing nursing care to patients.
The organization supports nursing service to provide systematic method of nursing care
with specific emphasis on Assessment, Planning, Implementation and Evaluation.
Nursing care is preventive, promotive, curative and rehabilitative in nature. Patient-
centered care supports active involvement of patients and their families in the design of
new care models and in decision-making about individual options for treatment.
The registered nurse, in collaboration with the patient, family and other team members
assesses, makes decisions, plans, implements, evaluates, and documents nursing care
based on reflection, current knowledge, and best practices.
Policies and procedures in concurrence with the laws and regulation guide the nursing
services in all functional units applicable in the organization.
Patient safety and nursing professionals safety is intertwined in every aspect of the
care. Nursing professionals practice in accordance with the Code of Ethics for
Registered Nursing professionals, establishes professional therapeutic relationships
with patients and advocates for and with patients throughout their interactions with the
health system.
Nursing services promote and initiate measures to create a learning environment that
supports patient advocacy and ethical practice.
Uniform nursing care is provided to all patients in different settings that include care
provided in outpatient units, various categories of wards, intensive care units, procedure
rooms, operation theatre, etc.
19
A designated senior nursing professional controls the care of vulnerable patients
(elderly, physically and/or mentally-challenged and children), patients undergoing
moderate sedation, patients under restraints, and end of life care.
20
Summary of Standard
21
Standards and Objective Elements
Standard
22
and updated regularly at least changing national,
once in annually. international
guidelines time to
time and GCP.
Standard
23
and special needs
etc.
c. The initial nursing assessment This shall be For definition of
results in a documented nursing documented by the “nursing care plan”
care plan. assigned nursing refer to glossary.
staff in the patient
record.
d. The care documentation must The documented This could also be
include preventive aspects of the nursing care plan done through
care where appropriate. should cover booklets/patient
preventive actions information leaflets
as necessary in the etc.
case and could
include diet, drugs,
etc.
In conditions where
it is not possible to
incorporate this at
the time of
assessment (e.g.
diagnosis not made/
unclear) the same
shall be done as
soon as a definite
diagnosis is arrived
at.
Standard
24
Sr.No Objective Elements Interpretation Remark(s)
a. Patients are reassessed at After the initial Every patient shall
appropriate intervals. assessment, the be reassessed at
patient is least once every
reassessed shift by the caring
periodically and this nurse.
is documented in Reassessments
the case sheet. The shall be done for
frequency may be day care patients
different for different (Before discharging)
areas based on the or patients awaiting
setting and the admission/ bed.
patient‟s clinical
condition and
requirements, e.g.
patients in ICU and
ER need to be
reassessed more
frequently
compared to a
patient in the ward.
Reassessments
shall also be done
in response to
significant changes
in patient‟s
condition.
b. Patients are reassessed at the Self-explanatory. Self-explanatory.
time of receiving and transferring
25
from one unit to another.
c. Patients are also reassessed Self-explanatory. Self-explanatory.
before and after shifting for
investigations.
d. Nursing care plan is modified Self-explanatory. Self-explanatory.
when emergency situations arise.
e. Nursing professionals evaluate Self-explanatory. Self-explanatory.
outcomes using reassessment
and revise action plans as
needed.
Standard
26
Standard
NCP.5. The nursing care planned and provided by the nursing professionals is
recorded.
Standard
NCP.6. The nursing care is individualized to address the needs of patient and
27
family.
28
Standard
Standard
NCP.8. There shall be established policies and protocols for vascular access
devices. (VADs).
29
access devices.
b. The nurse shall select the Self-explanatory. This to be based on
appropriate type of catheter prescribed therapy
(peripheral or central) to meet the or treatment
patient‟s vascular access needs. regimen, length of
treatment, duration
of dwell, vascular
integrity, patient
preference, and
ability and resource
available to care for
the device.
c. The catheter selected shall be of Self-explanatory. Self-explanatory.
the appropriate gauge and length
with the fewest number of lumen
and shall be the least invasive
device needed to accommodate
and manage the prescribed
therapy.
d. The nurse shall not alter the Self-explanatory. Self-explanatory.
vascular device outside the
manufacturer‟s direction for use.
e. Vascular access bundle care (for Self-explanatory. CDC guidelines can
prevention of complications) be used as
should be followed. references.
Standard
30
Sr.No Objective Elements Interpretation Remark(s)
a. A senior suitably experienced These include Self-explanatory.
nursing professional should guide Intensive care and
and supervise the nursing high dependency
professionals in each shift in each units, wards,
department. emergency unit, and
specialized areas
like cath lab,
endoscopy, dialysis,
etc.
b. Senior nursing professionals are Self-explanatory. Self-explanatory.
responsible for the
implementation of the policy,
protocol and procedures of the
respective areas.
c. The scope of services for senior Self-explanatory. Self-explanatory.
nursing professionals includes
supervision and monitoring of all
nursing activities related to patient
safety, quality of nursing care
rendered and turnaround time.
d. The nursing professionals should Self-explanatory. Self-explanatory.
ensure availability of patients
reports in their respective records.
e. Nursing professionals seek Self-explanatory. Self-explanatory.
additional knowledge and
assistance as needed, in a timely
manner.
f. Nursing professionals recognize Self-explanatory. Self-explanatory.
any limitations to safe, competent,
and ethical care and report
31
concerns and consult and/or
initiate appropriate changes as
necessary.
g. Nursing professionals evaluate, Self-explanatory. Self-explanatory.
disseminate, and support the
integration of evidence based
practice findings into practice.
Standard
NCP.10. The nursing care of vulnerable patients (elderly, children, physically and/or
mentally challenged) shall be supervised by senior nursing professionals.
32
Standard
NCP.11. The nursing care of patients under restraints (physical and/or chemical) shall
be supervised by senior nursing professionals.
Standard
33
provide care both
pharmacological and non-
pharmacological care based on
the hospital policy.
d. The organization respects and Self-explanatory. Self-explanatory.
supports nursing management of
pain for such patients.
e. The nursing professionals Self-explanatory. Self-explanatory.
educate the patient and their
family on various pain
management techniques
wherever appropriate.
Standard
NCP.13. Appropriate end of life care shall be provided to patients needing the same
by the nursing professionals.
34
helping them to cope
psychologically.
d. Nursing professionals are Self-explanatory. Self-explanatory.
educated and periodically trained
on end of life care.
35
CHAPTER: 3
MEDICATION OF MANAGEMENT
The nursing personnel should have an oversight of all medications stocked in the ward
and other clinical areas and should ensure good inventory control practices including
correct storage (as regards to temperature, look-alike, sound-alike etc.), monitoring
expiry dates and maintenance of documentation in the clinical areas.
36
The process also includes monitoring of patients after administration and procedures for
reporting and analyzing medication errors. Process should include duration of
monitoring after administration of high alert medication and medication used for
managing pain.
Patients and family members are educated about safe medication. Medications also
include blood, chemotherapy and self-administered medication.
There shall be a policy on verbal orders which would enable nursing professionals to
accurately capture all verbal orders affecting care of patients. Nursing professionals will
report and closely monitor the occurrence of adverse events including adverse drug
event.
37
Summary of standards
MOM.1. Indenting of required medication and stores will be done and supervised by
nursing staff made responsible for this function. Storage of medication in
the wards and other therapeutic areas shall be supervised by responsible
nursing professionals.
MOM.2. The dispensing, administration and accounting of medicines shall be carried
out by the concerned personnel and should be appropriately supervised by
senior nursing staff.
MOM.3. The monitoring of patients after medication administration is supervised by
responsible personnel.
MOM.4. The nursing professionals must report near misses, medication errors and
adverse drug events as per the policy of the HCO for analysis by the
appropriate staff predefined and identified by the HCO. Feedback is
provided to staff which includes the results of analysis and recommended
preventive measures for implementation by the nursing staff wherever
appropriate.
MOM.5. The organization shall ensure that it has a policy on verbal orders which will
be applicable to doctors, nursing professionals and technicians uniformly.
38
Standards and Objective Elements
Standard
MOM.1. Indenting of required medication and stores will be done and supervised by
nursing staff made responsible for this function. Storage of medication in
the wards and other therapeutic areas shall be supervised by responsible
nursing professionals.
39
or theft. The overall days, it shall be
ventilation, done on all working
cleanliness of the days.
storage area shall To check for loss or
be maintained. theft the
organization could
conduct audits at
regular intervals (as
defined by the
organization) to
detect such
instances.
c. Sound inventory control practices Organization shall Nursing
guide storage of the medications. follow or professionals will be
demonstrate ABC, trained and made
VED, FSN, FIFO- aware regarding the
led time analysis, need to adhere to
etc. The medicines sound inventory
shall be stored in management
alphabetical or practices.
company‟s name.
First expiry and first
Out policy should be
adhered to.
d. Sound-alike and look-alike Many drugs in The organization
medications are identified and ampoules, vials or can follow a method
stored separately. tablets may look- of storing drugs by
alike or sound-alike. generic name in an
They should be alphabetical order to
documented, address this issue.
segregated and
40
stored separately at The list will have to
all locations. be identified at
An effort to address regular intervals
this issue should be depending on the
made while defining changes in the
the formulary and formulary and
during the changes in
procurement of packaging (in case
drugs. of look-alike).
e. The list of emergency medications This list shall be A crash cart would
is defined and is stored in a prepared in help the
uniform manner. consonance with organization to store
good clinical these medications
practices and in a standardized
documented. List of manner, i.e. the
drugs shall be rows and drawers
uniform across the have defined
organization, medicines.
however the No other drugs shall
quantity can differ. be kept stored with
emergency
medications.
f. Emergency medications are Adequate quantity Nursing staff must
available all the time. of emergency know from where to
medicines should obtain emergency
be stocked at all medicines in the
times. Re-order eventuality of a
level at definite stock out during
quantity should be hours when the
clearly delineated. pharmacy / medical
stores may be
41
closed.
g. Emergency medications are Self-explanatory. In case the
replenished in a timely manner An inventory check organization follows
when used. shall be done at a system of sealing
least daily to ensure the emergency cart
this. then the check shall
be carried out
before re-sealing
every time.
Standard
MOM.2. The dispensing, administration and accounting of medicines shall be carried
out by the concerned personnel and should be appropriately supervised by
senior nursing staff.
42
drug. parenteral drugs,
anesthetic drug
preparation in
OTs, antibiotics,
chemotherapy and
high risk drugs
c. Patient is identified prior to Self-explanatory.
administration. Identification shall be
done by unique
identification number
(e.g. hospital
number/IP number,
etc.) and/or name.
d. Medication is verified from the Staff administering If any of the
order prior to administration. medications should parameters with
go through the respect to an order
treatment orders namely name,
before administration dose, route or
of the medication and frequency/time are
then only administer missing/incomplete
them. It is preferable the medication
that they also check administration
the general shall be deferred.
appearance of the However, to
medication (e.g. ensure that patient
melting, clumping care does not
etc.) before suffer a verbal
dispensing. order may be got
from the treating
doctor followed by
ratification of the
43
same (refer to
MOM 4i).
In case of high risk
medication(s), the
verification shall be
done by at least
two staff (nurse-
nurse or nurse-
doctor)
independently and
documented.
e. Dosage is verified from the order Self-explanatory. Self-explanatory.
prior to administration.
f. Route is verified from the order Self-explanatory. Where applicable
prior to administration. the site of
administration
shall also be
verified.
g. Timing is verified from the order Self-explanatory. The organization
prior to administration. needs to define the
timing of
administration of
medications. For
example, o.d, b.i.d,
t.i.d, q.i.d, h.s.
h. Patient is monitored during the IPD protocols should Nursing
administration of blood and blood identify the professionals
products, chemotherapy and parameters to be should be trained
other invasive procedure. monitored during to recognize alerts
administration of for individual
medications. medications that
44
may be used
infrequently in their
wards /
departments.
I. Medication administration is The organization The records shall
recorded. shall ensure that this reflect the actual
is done in a uniform administration. For
location and it shall example, if brand
include the name of Y was given in
the medication, place of brand X
dosage, route of (same generically)
administration, timing the documentation
and the name and shall be of brand
signature of the Y. Similarly, if the
person who has order was for a
administered the tablet of 250 mg
medication. but the
In case of infusions, administration was
it shall capture the ½ a tablet of 500
start time, the rate of mg the latter shall
infusion and end be documented.
time.
Standard
MOM.3. The monitoring of patients after medication administration is supervised by
responsible personnel.
45
administration. should be familiar medicines.
with common Senior nursing staff
adverse drug should supervise
reactions of the junior nursing
medications. professionals
They should know involved in
how to recognize an monitoring critically
anaphylactic , any ill and post op
other adverse drug patients.
reaction and the
immediate response
required; both
therapy and
escalation.
b. Monitoring of patients shall be Self-explanatory. Self-explanatory.
done after transfusion of blood
and blood products.
c. Monitoring of patients shall be Self-explanatory. Self-explanatory.
done after chemotherapy.
d. Monitoring of patients shall be Self-explanatory. Nursing
done in all post-operative cases professionals must
or where invasive procedures are be trained to carry
carried out. out a step wise de-
escalation of
monitoring
parameters based
on clinical
directions.
46
Standard
MOM.4. The nursing professionals must report near misses, medication errors and
adverse drug events as per the policy of the HCO for analysis by the
appropriate staff predefined and identified by the HCO. Feedback is provided
to staff which includes the results of analysis and recommended preventive
measures for implementation by the nursing staff wherever appropriate.
47
d. Corrective and/or preventive A feedback Nursing
action(s) are taken based on the mechanism is professionals and
analysis where appropriate. standardized in the paramedical staff
hospital. are aware of the
feedback
mechanism and
acknowledge the
feedback
appropriately.
Standard
MOM.5. The organization shall ensure that it has a policy on verbal orders which will
be applicable to doctors, nursing professionals and technicians uniformly.
48
as defined by organization.
e. Where verbal orders are given, Self-explanatory. Nursing
ratification shall be done at the professionals
earliest and not later than 24 hrs. should be
empowered to seek
endorsements by
the clinicians within
the specified
timeframe.
49
CHAPTER: 4
The organization shall ensure that nursing professionals are trained in communication
skills. Patients are informed of their rights and educated about their responsibilities at
the time of admission. They are informed about the disease, the possible outcomes and
are involved in decision making. The patients are educated about the mechanisms
available for addressing grievances.
Patient and families have a right to information and education about their healthcare
needs in a language and manner that is understood by them and proper timely
guidance shall be given by the nursing staff.
50
Summary of standard
ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.
ECG.2. Nursing professionals shall maintain confidentiality of all patient information.
ECG.3. Nursing professionals communicate with patient, family and relevant team
members to reflect continuity of care as and when required.
ECG.4. Patient and family are educated where essential and in case of any change
in nursing care plan.
51
Standards and Objective Elements
Standard
ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.
Standard
52
a. The nursing professionals are The nursing Self – explanatory.
aware of patient rights. professionals are
made aware of
patient and family
rights at the time of
induction.
b. Nursing professionals maintain Self-explanatory. Self-explanatory.
the confidentiality of patients
information.
c. Nursing professionals maintain Self-explanatory. Self-explanatory.
privacy of the patients during Female nurse will
care. give care to male
patient only if
another female staff
or family member is
present. Same
holds true vice
versa for male
patient. The same
holds true when a
male nurse provides
care for a female
patient.
d. The nursing professionals support Self-explanatory. Self-explanatory.
individual patient and family
beliefs, values and customs and
involve the patient and family in
decision making processes.
53
Standard
Standard
ECG.4. Patient and family are educated where essential and in case of any change
in nursing care plan.
54
safe and effective
use of medications,
food drug
interactions, diet
and nutrition,
immunisations, etc.
and preventive
aspects.
b. The education shall cover the Self-explanatory. This could be done
medical condition, pre and post- through patient
operative education, special education booklets /
procedures, preventing healthcare videos/ leaflets, etc.
associated infections, when to
seek urgent medical attention and
home care wherever applicable.
c. Nursing professionals explain to Self-explanatory. Self-explanatory.
patient/ family before any
procedures are performed on
patients.
d. Nursing professionals ensure This should be Self-explanatory.
written informed consent ensured for all
wherever essential. invasive
procedures, blood
and blood product
transfusions and
prior to
administration of
anaesthesia.
e. Patient and/or family are Self-explanatory. Self-explanatory.
educated in a language and
format that they can understand.
55
CHAPTER: 5
The standards guide the provision of an effective infection control programme in the
organization. There shall be a designated Infection control nurse.
The organization provides proper facilities and adequate resources to support the
Infection Control Practices.
The practices includes an action plan to minimize hospital acquired infections, control
outbreaks, disinfection/ sterilization activities and their monitoring, biomedical waste
(BMW) management, employee health and training of nursing staff.
56
Summary of Standard
57
Standards and Objective Elements
Standard
58
Standard
59
practices. appropriate sample Hygiene Observation
size shall be chosen Form”.
and all categories of Another tool that can
staff (involved in be utilised is use of
direct patient care) Infection control
shall be monitored. assessment tool
(ICAT).
d. The nursing staff adheres to It shall be Infection control
cleaning, disinfection and addressed at all assessment tool
sterilization practices. levels of the (ICAT) can be
organization, e.g. utilised for
ward and OT. It is monitoring of
preferable that the sterilisation and
organization follows disinfection
a uniform policy practices.
across different
departments within
the organization.
e. The nursing staff adheres to safe Self-explanatory. Nursing staff is
linen management practices. aware and use
appropriate PPE
while handling dirty
and soiled linen.
Nursing staff is
aware of safe
storage and
transport of used
linen.
f. The nursing staff adheres to the Self-explanatory. Self-explanatory.
safe injection practices.
g. The senior nursing professionals Self-explanatory. ICAT may be used
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along with other professionals for such monitoring.
identified by the HCO monitor
safe linen management practices.
Standard
ICP.3. The nursing professionals shall adhere to handling, storage and disposal of
bio medical waste as per the bio medical waste management Act, 1998.
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7. Cap/ hair cover.
Standard
ICP.4. The designated nursing staff shall perform surveillance activities to capture
and monitor infection control and prevention data.
62
construction or
repairs are
undertaken,
especially in high
risk areas.
b. Appropriate feedback regarding The feedback shall This could be in the
HAI rates are provided on a include the rates, form of a
regular basis to appropriate trends and bulletin/newsletter,
personnel. opportunities for or periodic circulars
improvement. It and meetings.
could also provide
specific inputs to
reduce the HAI rate.
c. The surveillance activities include Self-explanatory. This includes
monitoring of environment and monitoring of SSI,
infection control indicators. VAP, CLABSI,
CAUTI.
d. The surveillance activities include Self-explanatory. This includes
monitoring of cleaning, monitoring of
sterilization and disinfection in terminal cleaning
patient care units. procedures,
monitoring efficacy
of disinfectants in
use through
appropriate
measure.
Standard
ICP.5. Isolation (barrier and reverse barrier nursing) practices shall be supervised
by senior nursing professionals.
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Sr.No Objective Elements Interpretation Remark(s)
a. The organization provides The organization Refer to glossary for
appropriate resources for isolation shall define the “isolation/barrier
practices. conditions where nursing”.
isolation is required Ideally patients
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aisle or other rooms
should be kept
closed at all times.
Appropriate signage
shall be used/
displayed.
b The Nursing professionals are Self-explanatory. Self-explanatory.
familiar with the type of isolation
(barrier and reverse barrier)
facilities provided by the HCO.
c Senior Nursing Professionals Self-explanatory. Self-explanatory.
monitor the nursing activities This should include
provided in isolation facilities. monitoring of
standard
precautions,
disinfection and
sterilization of the
facility and
earmarking of
specific and trained
nursing staff for
carrying out duties
in such facilities.
Standard
ICP.6. Infection Control Nurse maintains records of all occupational injuries and
pre- and post-exposure prophylaxis.
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a. Hazardous materials specific to The nursing shall The hazardous
the settings and locations that identify, list and materials include
they work in are identified by the document the blood, body fluids
nursing professionals. (as hazardous materials as well as some
applicable). and has a chemicals and
documented drugs like
procedure for their chemotherapeutic
sorting, storage, agents. The
handling, hazardous materials
transpirations, identified should be
disposal specific to the work
mechanism, and place that they work
method for in and not a
managing spillages generalised list of
and adequate items across the
training of the HCO.
personnel for these
jobs.
b. The nursing professionals The organization Self-explanatory.
implement processes for sorting, has ensured display
labeling, handling, storage, of Material Safety
transporting and disposal of Data Sheets
hazardous materials. (MSDS) for all
hazardous materials
and has accordingly
arranged training of
personnel who
handles such
materials.
c. The Nursing professionals are Self-explanatory. The organization
aware of the HCOs plan for could have a
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managing the spills of hazardous HAZMAT kit(s) for
materials and are able to handling spills. The
supervise and adequately nursing staff should
implement the same in their be aware of the kit
specific locations of work. and the
methodology of use
of the kit in their
area of work.
d. Appropriate pre- and post- Self-explanatory For example,
exposure prophylaxis is provided Infection control hepatitis B
to all staff members concerned. Nurse maintains Vaccination and
documentation of all immunisation status
occupational injuries shall be available
and pre- and post- with designated
exposure individuals. And
prophylaxis records. PEP (e.g. Hepatitis
B immunoglobulin,
anti-retroviral drugs
for pregnant and
non-pregnant staff)
for needle stick
injury should be
administered within
desired time frame.
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CHAPTER: 6
The Nursing Service is led by qualified professionals with desired experience. Nursing
professionals are involved in decision making processes. They are encouraged to
participate in organization decision making groups and committees. There is a
commitment to support and reward nursing staff from time to time.
Nursing professionals at the bedside are empowered to take decision to meet the needs
of patients in collaboration with the care provider team. Nursing professionals at the bed
side participate in plan of treatment and discharge plan by the medical team.
Leaders ensure that patient-safety and risk-management issues are an integral part of
patient care and hospital management.
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Summary of Standards
69
Standards and Objective Elements
Standard
70
management lay down the values refer to of nursing manual,
nursing department values. glossary. refer NCP 1.
Only a display on its
website would not
be appropriate. It is
preferable that the
same be translated
and displayed in the
local language also.
d. Those responsible for nursing The nursing This should be part
management establish the management shall of nursing manual,
nursing department organogram. have a well-defined refer NCP 1.
organization
structure / chart and
this shall be clearly
document the
hierarchy, line of
control, along with
the function at the
various levels.
Standard
EG.2. The Head of the Nursing service ensures that suitable mechanisms exist to
govern the nursing Service.
71
selected based
upon identified
criteria like
qualifications,
experience and
training received.
b. The scope of Nursing services is Self-explanatory. Self-explanatory.
defined in the nursing manual.
72
Standard
EG.3. Nursing professionals are involved and participate in decision making related
to organization and nursing services.
73
other staff regarding the quality of identified and
nursing care and to for evaluating implemented
nursing satisfaction. accordingly.
Standard
Standard
EG.5. The organization has an established process for proactive risk assessment
74
and error management.
75
emergency and life threatening
situations arise.
Standard
76
infection control
programme.
c. The organization conducts Self-explanatory. Self-explanatory.
appropriate “in-service” training
sessions for all staff at least once
in a year.
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CHAPTER: 7
Nursing care quality improvement programme should be documented and involve all
areas of the organization and all essential nursing staff members. The organization
should collect data on structures, processes and outcomes, in nursing care areas. The
collected data should be collated, analysed and used for further improvements. The
improvements should be sustained.
78
Summary of Standard
79
Standards and Objective Elements
Standard
80
Standard
81
d. Monitoring of accidental delining Self-explanatory. Self-explanatory
(if applicable).
e. All extravasations are recorded Self-explanatory. Self-explanatory.
and monitored as per the laid
down protocols.
f. All needle stick injuries are Self-explanatory. Self-explanatory.
documented and monitored as
per the policy laid down by the
HCO that should be in
consonance with the national and
International guidelines.
g. All restraint related incidents Self-explanatory. Self-explanatory.
including strangulation are
monitored and documented.
h. The hand hygiene compliance is Self-explanatory. Self-explanatory.
monitored and recorded by the The monitoring
nursing professionals responsible should be as per the
for the same. criteria identified by
the WHO guidelines
on Hand Hygiene.
i. The compliance with pain Self-explanatory. Self-explanatory.
assessment and management is
monitored by the senior nursing
professional while undertaking
their professional rounds and the
same is documented.
j. The satisfaction of patients with Self-explanatory. Self-explanatory.
the nursing care is monitored by
the senior nursing professionals
and the same is documented.
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Standard
83
d. The attrition rate and frequency of Self-explanatory. Self-explanatory.
attrition of the nursing
professionals is monitored and
documented by the head of the
nursing in consultation with the
human resource department of
the HCO.
Standard
84
documentation based,
cost based, community
based or based on
morbidity (length of
stay).
It shall lay down the
objectives, the
parameters that are
going to be captured,
develop a checklist
where required,
sampling and data
collection guidelines and
preparation of report.
c. Patient and staff anonymity is This means that the This is at the stage
maintained. names of the patients of report
and the hospital staff preparation and
who may figure in the dissemination. The
audit documents must staff participating in
not be disclosed or any the audit shall
reference be made to maintain patient
them in public and staff anonymity
discussions/conferences. and not reveal
names.
d. All audits are recorded and Self-explanatory. The organization
reviewed. could use a
checklist with the
predefined
parameters and the
audit findings could
be recorded on this
85
sheet.
e. Implementation is recorded All remedial measures This should
and reviewed. as ascertained should be preferably be done
documented and based on root-
implemented and cause analysis.
improvements thereof
recorded to complete the
audit cycle.
Standard
NQI.5. Incidents, complaints and feedback from nursing professionals are collected
and analysed to ensure continual quality improvement.
86
processes for analysis of improvement preferably be done
incidents, feedbacks and committee (refer to by identifying the
complaints. CQI 1a) shall be root cause.
responsible for this Where possible, it is
activity. preferable that
patients be included
in analysing the
feedback and
complaint.
d. Corrective and preventive actions The objective of this All such action shall
are taken based on the findings of is to continually be documented.
such analysis. improve the quality
of patient-care
services.
87
GLOSSARY
The commonly-used terminologies in the NABH standards are briefly described and
explained herein to remove any ambiguity regarding their comprehension. The
definitions narrated have been taken from various authentic sources as stated,
wherever possible. Notwithstanding the accuracy of the explanations given, in the event
of any discrepancy with a legal requirement enshrined in the law of the land, the
provisions of the latter shall apply.
Adverse drug Adverse event: Any untoward medical occurrence that may
event present during treatment with a pharmaceutical product but
which does not necessarily have a causal relationship with this
treatment.
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for these terms, including harm caused by a
• drug
• harm caused by drug use, and
• a medication error with or without harm
Institute of Medicine: “An injury resulting from medical
intervention related to a drug”, which has been simplified to “an
injury resulting from the use of a drug”
89
the outside world. The nursing professionals wear gowns,
masks, and gloves, and they observe strict rules that labeling the
risk of passing on infectious agents.
Basic life Basic life support (BLS) is the level of medical care which is used
support for patients with life-threatening illnesses or injuries until the
patient can be given full medical care.
90
ISO 9000: 2000).
91
Disciplinary Sequence of activities to be carried out when staff does not
proceedings conform to the laid-down norms, rules and regulations of the
healthcare organization.
Family The person(s) with a significant role in the patient‟s life. It mainly
includes spouse, children and parents. It may also include a
person not legally related to the patient but can make healthcare
decisions for a patient if the patient loses decision-making ability.
92
term. Goals are ends that guide actions. (MBNQA)
93
education/ for enhancing the skills of staff members or for teaching them
training new skills relevant to their jobs/tasks.
Inventory control The method of supervising the intake, use and disposal of
various goods in hands. It relates to supervision of the supply,
storage and accessibility of items in order to ensure adequate
supply without stock-outs/excessive storage. It is also the
process of balancing ordering costs against carrying costs of the
inventory so as to minimise total costs.
94
characteristics required for competent performance of the
job. A job description should describe and focus on the job
itself and not on any specific individual who might fill the job.
Job specification 1. The qualifications/physical requirements, experience and
skills required to perform a particular job/task.
2. A statement of the minimum acceptable qualifications that
an incumbent must possess to perform a given job
successfully.
Laws Legal document setting forth the rules of governing a particular
kind of activity, e.g. organ transplantation act, which governs the
rules for undertaking organ transplantation.
Medication error 1. A medication error is any preventable event that may cause
or lead to inappropriate medication use or harm to a patient.
(FDA)
2. A medication error is any preventable event that may cause
or lead to inappropriate medication use or patient harm while
the medication is in the control of the healthcare professional,
patient, or consumer. Such events may be related to
professional practice, healthcare products, procedures, and
systems, including prescribing, order communication, product
labeling, packaging, and nomenclature, compounding,
dispensing, distribution, administration, education,
monitoring, and use.(NCC MERP)
Mission An organization‟s purpose. (ASQ)
This refers to the overall function of an organization. The mission
answers the question, “what is this organization attempting to
accomplish?” The mission might define patients, stakeholders, or
markets served, distinctive or core competencies, or
technologies used. (MBNQA)
Monitoring The performance and analysis of routine measurements aimed
95
at identifying and detecting changes in the health status or the
environment, e.g. monitoring of growth and nutritional status, air
quality in operation theatre. It requires careful planning and use
of standardised procedures and methods of data collection.
Errors that did not result in patient harm, but could have, can be
categorised as near-misses.
96
care, in terms of their use of resources and the outcomes for
patients/clients, and introduces appropriate change in response
to that analysis (NHS ME, 1991 Framework for Audit for Nursing
Services).
Patient-care The location where a patient is provided health care as per his
97
setting needs, e.g. ICU, speciality ward, private ward and general ward.
98
Technique project.
(PERT)
PERT breaks down the project into events and activities, and
lays down their proper sequence, relationships, and duration in
the form of a network. Lines connecting the events are called
paths, and the longest path resulting from connecting all events
is called the critical path. The length (duration) of the critical path
is the duration of the project, and any delay occurring along it
delays the whole project. PERT is a scheduling tool, and does
not help in finding the best or the shortest way to complete a
project.
99
assurance that quality requirements will be fulfilled (Para 3.2.11 of ISO
9000:2000).
100
http://www.preventionweb.net/english/ professional/terminology/].
Senior Nursing The act or function of rendering advice or showing the correct
professional path on educational or vocational matters.
101
contractual personnel and volunteers.
102
Transfusion A transfusion reaction is a problem that occurs after a patient
reaction receives a transfusion of blood.
Unstable patient A patient whose vital parameters need external assistance for
their maintenance.
Vascular Access Catheters, tubes, or device inserted into the vascular system,
Device including veins, arteries, and bone marrow.
Vulnerable Those patients who are prone to injury and disease by virtue of
patient their age, sex, physical, mental and immunological status, e.g.
infants, elderly, physically- and mentally-challenged, those on
immunosuppressive and/or chemotherapeutic agents.
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