Académique Documents
Professionnel Documents
Culture Documents
NURSING SERVICES
2008 Edition
STANDARDS OF
NURSING SERVICES
IV. Standards on Communication Management III. Standards on Patient and Family Education has
Standard I. Communication of Information two criteria in which the nurse’s independent role in
Standard II. Patient Clinical Record providing health education is hereby identified.
Standard III. Administrative Record
IV. Standards on Access and Continuity of Care.
V. Standards on Quality Improvement There are seven (7) criteria that guide the nurses
Standard I. Leadership and Staff Education regarding the importance of access to care. These
Standard II. Quality Programs
standards identify the need to establish policies and
Standard III. Quality Monitoring, Analysis and Implementation
procedures from admission to discharge and referral
follow up.
needed in the delivery of nursing services and
training of personnel to effectively carry out their
respective roles.
The second part is the Administration and Management. V. Standards on Quality Improvement. This
This concerns managing the nursing services in the hospital. standard has three (3) criteria which address the
There are five (5) standards identified: need to institutionalize continuous quality and
performance improvement.
I. Standards on Governance and Direction. There
are seven (7) criteria included. This chapter Each standard and criteria has identified measurable
recommends the need for organizational structure elements intended to provide clarity to the standards and to help
which will delineate responsibility, accountability organizations develop their own policies and procedures
and authority of nursing administration. These focus according to the standards.
also on planning, direction, organization and
controlling functions of the nursing service
administration and their relationship with other
services.
1. There is an evidence of initial and completion of 1. There is a well defined policy on nursing assessment
nursing assessment on the health care needs of each in terms of scope and content which include but are
patient within the: not limited on the following:
1.1.1st 24 hours of admission as an in-patient or 1.1. Psychological
earlier as indicated by the patient’s condition or • Knowledge level
institutional policy. • Language spoken
1.2.1st 2 hours of consultation as an outpatient or • Barriers to learning
earlier as indicated by patient’s condition or 1.2. Physical
institutional policy. • Neurological assessment
2. There is an evidence of patient’s reassessment • Cardiovascular assessment
throughout the care process to determine response to • Respiratory assessment
intervention at interval appropriate to patient’s • Gastrointestinal assessment
condition, plan of care, individual needs or • Genitourinary assessment
according to institutional policies and procedures • Musculoskeletal assessment
(e.g. Pain is assessed every 4 hours and as necessary
• Intergumentary assessment
as part of the vital signs monitoring).
• Sensory assessment 2.11.Value – Belief Pattern
1.3. Social 3. Other pertinent data are collected using the
• Cultural concerns appropriate assessment, technique and instruments.
1.4. Spiritual
• Religion
1.5. Economic factor
• Financial barrier
4. The nursing assessment findings are documented in
the individual patient’s record and readily available
1.6. Health history to those responsible for his/her care.
5. Discharge plan is evident in the initial assessment of
• Developmental history (for pediatrics)
the nurse particularly to those patients when
• Family history
discharge planning is critical as evidenced by the
• Medications taken following:
• Allergies 5.1. Age
1.7. Vital signs 5.2. Lack of mobility
1.8. Pain assessment 5.3. Continuing medical and nursing needs
1.9. Nutritional status, needs and risks 5.4. Assistance with activities of daily living
1.10.Preference and idiosyncrasies 5.5. Referral for continuity of care as necessary
1.11.Discharge plan
• Place: home, extended, skilled care II. Standards on Care of Patient
facility
• Individual who will accompany the patient Standard I: Care Process
home (name, address, telephone number,
relationship) The Nursing Services Department has an established
2. There is an established screening criteria according uniform care process across the clinical setting that reflects
to patients’ functional capacity and needs like: integration and coordination of care of other health team
2.1. Nutritional – Metabolic Pattern members particularly to those patients with similar
2.2. Elimination Pattern condition.
2.3. Activity – Exercise Pattern
2.4. Sleep – Rest Pattern Measurable Elements
2.5. Sexuality – Reproductive Pattern
2.6. Sensory – Perceptual Pattern 1. There are existing policies and procedures on care
2.7. Cognitive Pattern process developed by those responsible for
2.8. Role – Relationship Pattern governance which include but are not limited on the
2.9. Self – Concept Pattern following:
2.10.Coping – Stress Tolerance Pattern
1.1. Care of emergency patients (including use 1. There is a written care plan on every patient cared of
of resuscitation equipment) by the nurse based on patient’s initial assessment
1.2. Care of patient on life support (e.g. data within the 1st 24 hours of assessment or earlier.
ventilatory equipment) 2. There is an evidence that family and significant
1.3. Care of patient on dialysis (hemodialysis, others are involved in the planning process.
peritoneal dialysis) 2.1. Patient participate in planning of care taking
into consideration the cultural, religious and
other beliefs of patients. Example:
1.4. Care of patients at risk: Selection of food
• Neonates • Critically-ill 3. The care plan reflects the related and relevant
• Children • Mentally disadvantaged identified needs and problems of each patient cared
• Elderly • Under anesthesia for.
• Disabled 4. The care plan ensures that priorities of care are
1.5. Care of comatose patient established.
1.6. Care of patient with communicable diseases 5. The care plan is updated as appropriate based on the
1.7. Care of patient in restraint reassessment made.
1.8. Care of patient on chemotherapy 6. The care plan is documented in the individual
1.9. Care of immune - suppressed patients patient’s record to promote continuity of care.
1.10. Care of patient in pain
1.11. Care of patient on nutritional therapy Standard III: Implementation of Care
1.12. Care of patient receiving blood and blood
components The nurse caring for patients implements nursing
1.13. Care of patient receiving medications with intervention and carries out medical orders utilizing critical
narrow margin of safety thinking and sound clinical judgment for the promotion of
1.14. Care of perioperative patient health, prevention of illness, alleviation of suffering and
1.15. Care of patient with intravenous therapy restoration of health.
The nurse caring for patients develops and updates an 1. There is an evidence that nurse caring for patients
individualized written care plan in the patient’s record within implements nursing intervention and carries out
the prescribed time frame. medical orders utilizing critical thinking and sound
clinical judgment based on but are not limited on the
Measurable Elements following:
1.1. Scope of Nursing Practice as provided by law The nurse caring for patients systematically and
and all relevant legislations (e.g. The Philippine continuously evaluates the patient’s progress based on the
Nursing Act of 2002 or Republic Act 9173) effectiveness of nursing intervention rendered and medical
management provided.
The Nursing Services Department has established The nurse provides an end-of-life care to facilitate a
policies, procedures and guidelines on medication dignified and peaceful closure of life for patients through
management for symptomatic, curative, preventive, and physiological, psychological, social and spiritual care taking
palliative treatment of patients’ diseases and for safe nursing into consideration the cultural diversities in beliefs and
practice. customs and optimize caring environment.
1. There are written policies, procedures and guidelines 1. Respect for patient’s values, religion and cultural
on medication management which include but are preferences and practices is evident.
not limited on the following: 1.1. Pastoral services are provided based on the
1.1. Carrying out physician’s medication order spiritual beliefs of the patient and family.
1.2. Transcribing and ordering 1.2. The patient’s right of self-determination and
1.3. Endorsing (especially high valuable drugs) choices are respected and accommodated.
1.4. Preparing 1.3. Advance directives Do Not Resuscitate, Waiver,
1.5. Labeling Living will if any, are respected.
1.6. Administering (10 Golden Rules in Drug 1.4. Patient and family choices to donate organs and
Administration) other tissue are supported through provision of
1.7. Documenting relevant information. In accordance to statutory
1.8. Monitoring and Storage laws, rules and regulations.
1.9. Emergency Drugs 2. Assessment, appropriate intervention to alleviate the
1.10.Regulated Drugs patient’s pain and discomfort according to wishes of
1.11.Medication Recall System (Expired or patient and family and re-assessment are evident.
Outdated Drugs) 2.1. Pain assessment, intervention and evaluation,
1.12.Reporting on are monitored and recorded.
• Medication effects and adverse effects 2.2. Personal hygiene is rendered based on patient’s
• Medication error and near-miss need.
2.3. Nutritional assessment and risks are identified 1.7. Support patient and family rights by
and nutritional needs are provided such as participating in the care decision and care
feeding and hydration. process through information of the following:
2.4. Interventions address patient and family’s • Medical condition and confirmed
psychosocial, emotional, spiritual and cultural diagnosis and the informant
concerns. • Planned care, treatment, outcome of care,
3. A place is designated for the patient’s family to stay. unanticipated outcome and participation in
4. The patient and family are involved in care care decision according to wishes
management and decision. • Informed consent
• Refusal or discontinuance of treatment
Standard VIII: Patient and Family Rights • Withholding life-sustaining treatments
• Assessment and management of pain
The Nursing Services Department has established
policies, processes and guidelines that respect and support • Compassionate care at the end-of-life
patient and family rights. • Process on complaints and differences of
opinion about patient care
Measurable Elements • Participation in clinical research
• Organ donation and other tissues
1. There are written policies, processes and guidelines • Disclosure of information
that respect and support patient and family rights 2. There is evidence that nurses are knowledgeable and
which include but are not limited on the following: supportive of patient and family rights.
1.1. Prerogative to determine what information
regarding health condition and care is provided III. Standards on Patient and Family Education
to family and under what circumstances.
1.2. Respect for patient’s personal values and beliefs Standard I: Education Assessment
1.3. Respect the confidentiality of patient health
information The nurse assesses the educational needs of each patient
1.4. Respect for patient’s need for privacy (e.g. and family and documents these in his/her patient record.
during treatment, procedure, physical
examination, clinical interview, transport) Measurable Elements
1.5. Protection of patient’s possessions from theft or
loss 1. There is a written evidence that the nurse assesses
1.6. Protection of patient from physical assault (e.g. the educational needs of each patient and family
vulnerable patients are infants, children and which include but are not limited on the following:
elderly) 1.1. Patient’s and family’s beliefs and values
1.2. Patient’s and family’s literacy
1.3. Patient’s and family’s educational level
1.4. Patient’s and family’s language 5. It is evident that standardized materials and
1.5. Patient’s and family’s motivations and processes in educating patient and family on the
emotional barriers aforementioned topics (4.1 to 4.5) are available.
1.6. Patient’s physical and cognitive limitation 6. There is an evidence that nurses who provide
1.7. Patient’s willingness to receive information education have the subject knowledge, adequate
Standard II: Education Plan and Programs time and communication skills to do so.
The Nursing Services Department has established IV. Standards on Access and Continuity of Care
educational plans and programs that support patient and
family participation in care decisions and care processes Standard I: Access to Care
with the primary objective of rehabilitating the patient back
to his/her functional level and optimal health. In diverse health care setting, the Nursing Services
Department has established policies and processes on patient
Measurable Elements access to care aligned with the organization.
1. The educational plan and programs for patient and Measurable Elements
family are evident according to the type of patient
served and his/her learning needs. 1. The written policies and processes on patient access
2. The appropriate structure, methods and mechanism to care are evident which include but are not limited
for education is afforded. on the following:
3. Education resources are available and organized in 1.1. Clinical services available
an efficient and effective manner. 1.2. Triage or screening
4. When appropriate, it is evident that the patient and • There is evidence that triaging or
family are educated on topics considered high risk to screening is initiated at the point of 1st
patients: contact with the patient
4.1. Safe and effective use of medications and their 1.3. Criteria for admitting patient or registering
side effects out patient
4.2. Preventing interactions between prescribed 1.4. Process for admitting patient or registering
medications and other medications (over the out patient
counter) and food 1.5. Holding area for patient on observation
4.3. Safe and effective use of medical equipment 1.6. Managing patient when bed or space or
4.4. Pain management facilities is not available
4.5. Rehabilitation techniques
4.6. Treatment and diagnostic procedures Standard II: Emergency Patients
The patients with emergency or immediate needs/care 2.1. Proposed plan of care
are given priority for assessment and treatment by the nurse. 2.2. Expected outcome of care
2.3. Expected cost of care
2.4. Sufficient information to make knowledgeable
decision and
2.5. Limit or overcome barriers such as language,
cultural, physical, to access and in the delivery
of care
Measurable Elements Standard IV: Intensive and Specialized Services
1. There is an evidence that patients with immediate The Nursing Services Department has established entry/
needs/care are assessed, prioritized and received the or transfer criteria for patients that need intensive and
necessary care as quickly as possible according to specialized services to meet special patient needs congruent
established physiologically based criteria. with those of the organization.
2. There is an evidence that staff who responded to
emergency patients underwent the necessary Measurable Elements
training.
1. There is an evidence of entry/or transfer criteria for
Standard III: Admitted Patients or In-Patients patients that need intensive and specialized services
to meet special patient needs.
The needs of in-patients for preventive, curative, 2. It is evident that criteria is physiologic-based and
rehabilitative and palliative services as well as other relevant developed by appropriate individuals.
information are assessed and prioritized based on his/her 3. It is evident that patients admitted and or transferred
health condition at the time of admission in the health care to intensive and specialized areas/units meet the
facility. established criteria and are documented in the
patient record.
Measurable Elements 4. There is an evidence that nurses caring for patients
needing intensive and specialized services
1. There is an evidence that nurse screening assessment underwent the related and necessary training.
focuses on preventive, curative, rehabilitative and
palliative services and prioritizes these according to Standard V: Continuity of Care
the patient’s health condition.
2. There is an evidence that nurse actively participated In diverse health care setting, the Nursing Services
in providing relevant information to patient and Department has established policies and processes on patient
family during the admission process which includes continuity of care aligned with those of the organization and
but are not limited on the following: coordinated among other health professionals.
2. There are criteria that determine patients readiness to
Measurable Elements be discharged.
3. There is a process on out on pass patients for a
1. The written policies and processes on patient defined period of time.
continuity of care are evident and implemented 4. There is a referral system of patients for transfer to
throughout all phases of patient care particularly but other organization.
are not limited in the following services: 5. The patient’s discharge summary is prepared by
qualified individuals recognized by the organization.
1.1. Emergency services to nursing ward admission 6. A copy of patient’s discharge summary is placed in
1.2. Nursing ward services to diagnostic services the patient record and another copy is given to the
1.3. Nursing ward services to surgical and non- patient which include but are not limited on the
surgical services following:
1.4. Between nursing units or clinical departments 6.1. Reason for admission
1.5. Nursing ward services to intensive or special 6.2. Significant physical and other findings
services 6.3. Significant diagnosis and co-morbidities
1.6. Out patient care programs 6.4. Diagnostic and therapeutic procedures
1.7. Other health care settings performed
2. During all phases of care, there is a qualified 6.5. Medications and treatments
individual, identified as responsible for patient care 6.6. Medications to be taken at home
and documented in the patient record. 6.7. Condition of patient at the time of discharge
3. Continuity of care and coordination of services are 6.8. Follow-up instruction in an understandable form
evident throughout all phases of care. and manner
• Activity
Standard VI: Discharge, Out on Pass, Referral and • Diet
Follow-up • Next medical consultation
• Urgent care indicators
The Nursing Services Department has established 6.9. Referral for support services to either health care
policies and processes and guidelines on patient’s discharge, providers, health organizations or agency, and
out on pass, referral and follow-up congruent with those of health professionals in the community.
the organization.
Standard VII: Transfer of Patient
Measurable Elements
The Nursing Services Department has established
1. There are written policies, procedures and guidelines policies, procedures and guidelines regarding the transfer of
on patient’s discharge, out on pass, referral and patient within and outside of the organization.
follow-up congruent with those of the organization.
Measurable Elements applicable forms which include but are not limited
on the following:
1. There is a written policy, procedure and guidelines 1.1. Patient’s addressograph – name, age,
on transfer of patient within and outside of the gender, civil status
organization. 1.2. Registration number and or Admission
2. The guidelines and procedures include but are not number
limited on the following: 1.3. Date and time of admission and discharge
2.1. Transfer is based on the patient’s needs for 1.4. Mode of admission/transport/discharge
continuity of care. 1.4.1. Admitted via: ambulatory,
2.2. Transfer of responsibility to another health wheelchair, stretcher
provider or health care setting is evident. 1.4.2. Admitted from: home, transferring
2.3. Responsible health care provider during the hospital, care facility
patient’s transfer is identified. 1.5. Attending physician and referring physician,
2.4. Formal and informal arrangements are apparent. if any
2.5. Summary of patient’s clinical condition, 1.6. Religion
interventions (medical and nursing) and 1.7. Language spoken
continuous care rendered are written. 1.8. Advance directive
2.6. Situation when transfer is not possible is stated. 1.9. Health Care Insurance
2.7. Patient’s transfer is documented.
2.8. Safe and quality medical transport services Standard II: Clinical Data
within and outside of the organization are
provided. The nurse documents essential clinical data of each
patient accurately and completely based on individualized
V. Standards on Nursing Documentation nursing care plan from admission to discharge in health care
facility.
Standard I: Structural Data
Measurable Elements
The nurse documents structural data of each patient
accurately and completely based on applicable laws and 1. There is relevant/essential, accurate and complete
regulations, professional standards and institutional nursing documentation of patients’ clinical data in
requirements. all appropriate forms from admission to discharge
in health care facility which include but are not
Measurable Elements limited on the following:
1.1. Physical examination (head-to-toe)
1. There is an accurate and complete documentation 1.2. Health history
of patients’ structural data in all nursing and
1.3. Psychological, social, spiritual and
economic evaluation
1.4. Actual and potential health problems and ADMINISTRATION & MANAGEMENT
needs
1.5. Diagnostic and therapeutic interventions
I. Standards on Governance and Direction
1.6. Pharmacological management
1.7. Nursing interventions
Standard I: Governance Structure
1.8. Health teachings – patient and family
1.9. Patients’ response and outcome
The Nursing Services Department has governance
1.10. Preferences and idiosyncrasies
structure designed to delineate lines of relationship,
authority, responsibility and accountability and the
mechanisms for communication and coordination within the
Nursing Services and other services/departments of the
health care facility.
Measurable Elements
1. The governance responsibility and accountability are The Nursing Services Department has documented
described in organization’s by-laws, job description strategic and operational plans consistent with the hospital
and other similar documents. wide quality plan.
2. Those responsible and accountable for governing
and managing the Nursing Services Department are Measurable Elements
identified by position title and name.
3. Those responsible for governance appoint the 1. Those responsible for governance forecast and direct
Nursing Services Administrator, managers, the future and operation of the Nursing Services
professional technical staff and assistive nursing Department in order to achieve its overall goals.
personnel to carry out the functions of the Nursing 2. There is an existence of strategic and operational
Services Department. plans periodically set and reviewed which contains
4. There is a written document that describes how the goals and objectives, action plan/activities,
performances of the governing entity are appraised timeframe, resources required and contingencies.
by specific criteria. 3. Those in the managerial and clinical levels translate
the overall Nursing Services Department’ strategic
Standard III: Direction-Setting and management plans into action which include:
the management of patient care, nursing manpower
The Nursing Services Department has an established and unit operation of responsibility areas.
vision, mission, philosophy, core values and quality
objectives congruent with that of the institution and the Standard V: Financial Plan & Resource Allocation
Nursing profession.
The Nursing Services Department has financial plan and
Measurable Elements allocation of resources required to meet its goals and sustain
its operation.
1. Those responsible for the Nursing Services
Department governance, primarily sets its direction Measurable Elements
by formulating its vision, mission, philosophy, core
values and quality objectives congruent with that of 1. Those responsible for governance have established
the institution and the Nursing profession. current financial plans and allocation of resources
2. The vision, mission, philosophy and core values are based on the needs of the Nursing Services
written (specific, measurable, attainable, reliable, Department.
2. The capital and operating budgets are implemented conforms with the applicable statutory laws, rules and
as approved by the authorized person/office and regulations.
monitored based on responsibility accounting.
3. Each Nursing Unit has an individual budget plan
periodically monitored for variances. Measurable Elements
4. The medical supplies, materials and equipment
recommended by professional organizations and 1. Those responsible for governance formulate policies
authoritative sources are obtained and appropriately and procedures to serve as guidelines for those
used. confronted by ethico-moral dilemmas in patient care.
2. Those responsible for governance ensure compliance
Standard VI: Policies & Procedures Development with the applicable statutory laws, regulations and
standards.
The policies and procedures of the Nursing Services 3. The Nursing Services Department has a written
Department that reflect Standards of Nursing Code of Ethical Behavior which observes the rights
Administration, Nursing Practice on Patient Care are and safety of patients and health care providers.
developed and communicated to serve as operational
guidelines. Standard VIII: Professional & Organizational
Involvement
Measurable Elements
The administrator of the Nursing Services Department
1. Those responsible for governance develop and actively participates and collaborates with leaders within the
implement policies and procedures based on organization and professional associations for continuous
established Standards of Nursing Administration and quality improvement of nursing services.
Nursing Service on Patient Care.
2. An updated manual of Nursing Services policies and Measurable Elements
procedures exists and provides clear directive for
nursing personnel at different levels on the scope 1. Those responsible for Nursing Services Department
and limitations of their functions and responsibilities governance initiate and maintain formal
to patient care. liaison/linkage with other departments/sections of
the institution and professional associations and
Standard VII: Ethico – Moral & Legal Accountabilities agencies pertinent to nursing standards and
practices, professional and interprofessional
The Nursing Services Department has an established relationships and other related endeavors.
framework for ethico-moral and legal management to
support the ethical decision-making in the clinical areas, and
administration courses at the graduate
level; and
1.1.4. Be a member of good standing of the
accredited professional organization
of nurses.
II. Standards on Human Resource Management
1.2. A person occupying the position of chief nurse
Standard I: Administrator of Nursing Services of director of nursing service shall, in addition
to the foregoing qualifications, possess:
The Nursing Services Department is administered by a 1.1.1. At least five (5) years of experience
qualified nursing administrator pertinent to licensure, in a supervisory or management
appropriate education, experience and demonstrable proven position in nursing; and
ability in nursing practice and administration, fully 1.1.2. A master’s degree major in nursing.
responsible and accountable for the operation of the entire 1.3. That for primary hospitals, the maximum
Nursing Services of the organization/institution. academic qualifications and experiences for a
chief nurse shall be as specified in subsections
Measurable Elements (1.1.1), (1.1.2.), and (1.1.3) of the above.
1.4. That for chief nurses in the public health
1. There are presence of evidences that the Nursing agencies; those who have a master’s degree in
Service Administrator is qualified to the position public health/community health nursing shall
based on RA 9173 and other criteria set by the be given priority.
organization/institution such as: 1.5. That for chief nurses in military hospitals,
1.1 Qualifications of Nursing Service priority shall be given to those who have
Administrators: finished a master’s degree in nursing and the
A person occupying supervisory or completion of the General Staff Course
managerial positions requiring knowledge of (GSC).
nursing must: 2. Those responsible for the overall administration
1.1.1. Be a registered nurse in the and management of Nursing Services is a member
Philippines; of the top Executive/Management Committee who
1.1.2. Have at least two (2) years experience participates in their regular meetings and provides
in general nursing service advice and recommendations in relation to nursing
administration; practice.
1.1.3. Possess a degree of bachelor of
Science in Nursing, with a least nine Standard II: Staffing Plan
(9) units in management and
The Nursing Services Department has a staffing plan development of system and processes for
that identify the number, type and desired qualification of recruitment, selection, hiring, appointment and
nursing services staff which is written, reviewed and updated promotion of nursing service personnel in
on an ongoing basis. accordance with the statutory laws and regulations
and the institutional policies and procedures.
2. There are legitimate and legitimized processes to
recruit, select, hire and appoint nursing services
Measurable Elements personnel and are uniformly implemented.
3. Staff recruitment, selection, hiring and appointment
1. Those responsible for Nursing Services governance are based on institutional, patients’ needs and
develop a staffing plan that identify the number, type applicant qualification.
and desired qualification (education, skills and
experience) of Nursing Services staff, reviewed and Standard IV: Credentialing
updated on an ongoing basis.
2. Those responsible for Nursing Services governance The Nursing Services Department has an effective
consider the organization’s mission, type of services, process for gathering, verifying and evaluating the nursing
level and modality of care, patients’ mix, staff and staff credentials.
skills mix and other factors affecting the projection
of staffing needs. Measurable Elements
3. The staffing plan is defined in writing and meets the
needs of the patients/population served and scope of 1. Those responsible for Nursing Services governance
services. develop an effective process for gathering, verifying
and evaluating the nursing staff credentials
Standard III: Recruitment, Selection, Hiring and (licensure, education, training, work experience) and
Appointment other pertinent requirements.
2. There is evidence of standardized procedure to
The Nursing Services Department has an established gather the credentials of all nursing staff.
system and processes for recruitment, selection, hiring, 3. The licensure, education, training and work
appointment and promotion of human resources in experiences of nursing personnel are documented
accordance with the statutory laws and regulations and the and updated.
institutional policies and procedures.
Standard V: Staff Placement
Measurable Elements
The Nursing Services Department has defined criteria
1. Those responsible for the Nursing Services and processes to ensure the clinical staff knowledge and
governance actively participate/collaborate in the skills are consistent with the patients’ needs.
2. There is evidence that the Job Description of
Nursing Services personnel is reviewed at least once
every 3 years and revised when necessary.
Measurable Elements
1. Those responsible for Nursing Services governance Standard VII: Staff Development
develop and define the criteria (core competencies)
and processes to match the clinical staff knowledge The Nursing Services Department has an established
and skills with the patients’ needs. staff development program for all nursing personnel to
2. There are written core competencies required for encourage and promote continuing personal and professional
every job position in the Nursing Services growth and development.
organization to ensure that the staff skills are
consistent with the patients’ needs. Measurable Elements
3. Staff placement/assignment is based on patient
needs, available resources and staff competencies. 1. Those responsible for Nursing Services governance
design and implement staff development programs
Standard VI: Staff Job Description for nursing personnel at all levels based on training
needs analyses.
The Nursing Services Department has job description for 2. There is evidence of staff development programs for
each position classification of Nursing personnel, which all nursing personnel throughout the year which
specifies duties and responsibilities based on established include:
standards of performance. a. Orientation program for newly hired and
promoted staff, to the organization
Measurable Elements department/unit to which they are assigned as
well as their specific job responsibilities.
1. There is a written Job Description for each position b. Safety program to protect the patient, staff and
classification of Nursing Services personnel which property.
specifies: c. Continuing education, training and opportunities
1.1. Duties and responsibilities for professional advancement of staff member to
1.2. Accountability enhance their knowledge and skills.
1.3. Functional relationship d. Career counseling and career
1.4. Qualification and experience required advancement/ladder.
3. Resources are available to implement the staff
development program such as:
3.1. Space and facilities 2. Those responsible for governance actively
3.2. Educational resources participate in space planning as well as medical
3.3. Clinical and clerical staff equipment and supplies procurement.
3.4. Audiovisual equipment 3. Those responsible for governance, plan and budget
3.5. Resource speakers for upgrading or replacing key components based on
facility inspection findings.