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STANDARDS FOR NURSING EXCELLENCE

First Edition

October 2013

NATIONAL ACCREDITATION BOARD FOR

HOSPITALS AND HEALTHCARE

PROVIDERS

2

FOREWORD

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

3

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.

4

TABLE OF CONTENTS

Chapter No Particulars Page No.

Chapter:1 Nursing Resource Management (NRM)

Chapter:2 Nursing Care of Patient (NCP)

Chapter:3 Management of Medication (MOM)

Chapter:4 Education, Communication and Guidance (ECG)

Chapter:5 Infection Control Practices (ICP)

Chapter:6 Empowerment and Governance (EG)

Chapter:7 Nursing Quality Indicators (NQI)

Glossary

5

CHAPTER 1

NURSING RESOURCE MANAGEMENT

Intent of the chapter:

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.

There shall be an established procedure for addressing grievances.

6

Summary of Standard

NRM.1. The organization has a documented system of nursing resource planning.

NRM.2. The organization has structures and processes for induction and for

enhancing the transition of novices to competent nursing professionals.

NRM.3. The organization has processes in place for induction training, In-service

education and Continuous Nursing Education (CNE) programmes and for

documentation of the same in the personal files.

NRM.4.

There is a process for credentialing and privileging of nursing professionals,

permitted to provide patient care without supervision.

NRM.5. An appraisal system for evaluating the performance of nursing staff exists

as an integral part of the nursing resource management process.

NRM.6. There is a provision for acknowledging outstanding performances/

contributions of nursing professionals.

NRM.7. There is an established process in place to identify and manage problems

related to incompetent, unsafe or unprofessional conduct.

NRM.8. The organization demonstrates workplace safety for nursing professionals

and protection of their rights.

NRM.9.

The organization has a documented and established grievance handling

system.

7

Standards and Objective Elements

Standard

NRM.1. The organization has a documented system of nursing resource planning.

Sr.No Objective Elements Interpretation Remark(s)

a. Nursing resource

planning supports the

organization‟s current

and future ability to meet

the care, treatment and

service needs of the

patient.

It shall use recognised

methods for determining

levels of nursing staffing.

A yearly nursing plan is

to be documented, with

inputs from all

stakeholders including

the Nursing Head,

Medical Head, key

clinicians, HR and

Finance. This should be

in line with growth

projections, strategic

plans and budgets of the

hospital. In case higher

approvals are needed eg

in Govt sector, hospitals,

the plan approval will be

taken in advance of

implementation.

References may be

used. INC guidelines,

Acuity based norms etc.

The organization will

ensure that the plan

addresses staffing crisis

situations due to

attrition, and the hiring

plan ensures vacancies

are filled up early so that

patient care is not

compromised.

A contingency plan for

staffing in sudden high

occupancy levels is in

place. The deciding

parameters or

guidelines for nursing

manpower must be

clearly delineated.

b. The organization

maintains an adequate

number and mix of

nursing staff to meet the

The nursing staff should

be commensurate with

the workload and the

clinical requirement of

A good reference could

be the INC guidelines.

8

care, treatment and

service needs of the

patient.

the patients. Workload

on Nursing professionals

will be monitored.

c. The person heading the

nursing service has

requisite and appropriate

qualifications.

INC recognized

qualifications with

management

training/degree.

Self-explanatory.

d. The person heading the

nursing service has

requisite and appropriate

experience.

Self-explanatory As per INC guidelines /

MOHFW hospital

manual guidelines.

e. The required job

specification and job

description are defined

for each category of

nursing staff.

The content of each job

should be well defined

and the qualifications,

skills and experience

required for performing

the job should be clearly

laid down. The job

description should be

commensurate with the

qualification.

Refer to glossary for

definition of "job

description” and “job

specification". For a job

which requires the skills

of a nurse the minimum

qualification shall be a

GNM/ B.Sc Nursing.

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.


9

a. Nursing shift plans based upon

timings of shift, day or week shall

identify and depute nursing

professionals to various areas

based on their skills and

competencies.

For eg. if the shift

for a unit is eight

hourly then the

nursing

professionals doing

the shift at night

should have skills

and competencies

that enable her to

independently

monitor and handle

emergency

situations.

Self-explanatory.

b. Training need shall be identified

on a continual basis by the senior

nursing professionals as well as

the Clinical Heads as appropriate.

Self-explanatory. Self-explanatory.

c. Required competency parameters

shall be evaluated by such senior

nursing professionals and the

clinical and support service Heads

and shall be recorded in the

training records as in NRM 2.

These are generally

bed-side nursing

care procedures

and are therefore

evaluated on a

continual basis. The

recording may be

done at suitable

periodic intervals.

Self-explanatory.

Standard

NRM.3. The organization has processes in place for induction training, In-service

education and Continuous Nursing Education (CNE) programmes and for

10

documentation of the same in the personal files.


a. Every nurse entering the

organization is provided induction

training.

The organization

shall determine as

to when induction

training shall be

conducted.

However, it shall be

within 15 days of

the staff joining.

The contents of the

induction training

should be defined

and should include

issues related to

patient safety and

quality nursing care.

The contents of this

training could be

provided to every

nursing staff in the

form of a booklet.

There can be

separate induction

training at the

organizational level

and for the

respective

departments.

b. A documented training and

development policy exists for the

staff.

A training manual

incorporating the

procedure for

identification of

training needs, the

training

methodology,

documentation of

training, training

assessment, impact

of training and the

training calendar

The training shall be

for all categories of

nursing staff.

11

should be prepared.

c. The organization maintains

records of training.

The organization

shall maintain a

record of all

trainings provided.

At a minimum, it

shall include the title

of the training, the

trainer(s), list of

trainees (with

signatures) and the

post-training

feedback.

Where possible, the

contents of the

training may also be

captured. Regular

assessments of the

effectiveness of the

imparted training in

the respective work

locations must be

carried out and

records of the same

maintained.

d. Nursing professionals shall

receive adequate training when

there is a change in job

responsibilities or when new

equipment is introduced.

The training should

focus on the revised

job responsibilities

as well as on the

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

provide BLS. Nursing

professionals working in intensive


12

care/high dependency units shall

undergo training in ACLS or PALS

or NALS as applicable.

Standard

NRM.4.

There is a process for credentialing and privileging of nursing professionals,

permitted to provide patient care without supervision.


a. The education, registration,

training and experience of nursing

staff is recorded and updated

periodically.

This may be done

by a credentialing

and privileging

committee.

Updation is done

after acquisition of

new skills and/or

qualification after

verifying from the

various documents

and certificates.

b. Nursing staff permitted by law,

regulation and the organization to

provide patient care without

supervision are identified.

The organization

identifies the

individuals who

have the required

qualification(s),

training and

experience to

provide patient care

in consonance with

Refer to Indian

Nursing Council Act,

1947.

13

the law.

c. All such information pertaining to

the nursing staff is appropriately

verified when possible.

The organization

shall do the same

by verifying the

credentials from the

organization which

has awarded the

qualification/training.

Educational

parameters are

validated by

verifying the

qualification

certificates. 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

privileges in consonance with

their qualification, training,

experience and registration.

The organization

shall lay down

parameters for

identifying as to

what each nurse is

authorised to do.

It is preferable to get

the privileging done

through a

credentialing and

privileging. To be

read in conjunction

with NRM 4b

committee based on

For example, an

Infection Control

Nurse should have

had requisite in-

house/external

training and

experience and the

aptitude and

knowledge to

perform the tasks

required of her.

14

pre existing criteria /

parameters.

e. The requisite services to be

provided by the nursing staff are

known to them as well as the

various departments/units of the

organization.

Self-explanatory. This could be done

by internal

communication.

f. Nursing professionals care for

patients as per their privileging.

Self-explanatory.

New staff members

can be under the

proctorship till

independent

privilege is being

provided for each

staff.

The organization

could evolve a

mechanism to

ensure that nursing

professionals are

providing only those

services that they

have been

privileged to offer.

Standard

NRM.5. An appraisal system for evaluating the performance of nursing staff exists

as an integral part of the nursing resource management process.


a. A recorded performance

appraisal system exists in

the organization for

nursing professionals.

Self-explanatory. This shall be done for all

categories of nursing

staff starting from the

person heading the

nursing and including

nursing professionals

who are employees.

15

For definition of

“performance appraisal”

refer to glossary.

b. The nursing professionals

are made aware of the

system of appraisal at the

time of induction.

Self-explanatory.

This could be

incorporated in the

service booklet and

included in the induction

training.

c. Performance is evaluated

based on the pre-

determined criteria.

Self-explanatory.

The criteria for

assessment should be

defined and known to

the nursing

professionals. It is

preferable to have

objective criteria that

can be supplemented

by subjective remarks.

Key result areas are

identified for each

nursing staff and training

need assessment is also

done at the time of

assessment.

d. Performance appraisal is

carried out at pre-defined

intervals and is recorded.

Self-explanatory.

This shall be done at

least once a year.

Standard

NRM.6. There is a provision for acknowledging outstanding performances/

contributions of nursing professionals.


16

a. Patients, families and staff shall

be encouraged to report positive

feedback about nursing care

delivered in relevant areas.


b. Nursing staff with managerial

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

NRM.7. There is an established process in place to identify and manage problems

related to incompetent, unsafe or unprofessional conduct.


a. The process shall include daily

monitoring of appearance and

ability to impart nursing care.

Appearance,

Behaviour,

Communication, and

Decorum.

Self-explanatory.

b. The process shall include analysis

of all complaints pertaining to

nursing services specifically

addressing individual nursing

staff.

Self-explanatory. The process shall

ensure that there is

no victimization and

corrective action is

focused against the

system rather than

the individual.

c. The disciplinary policy and Self-explanatory. Principles of natural

17

procedure is based on the

principles of natural justice.

justice shall be

followed to ensure

that a nursing staff

against whom there

is a complaint, of

any sort, has the

right to explain

himself/herself.

Standard

NRM.8. The organization demonstrates workplace safety for nursing professionals

(including change rooms, washrooms & dining facilities).


a. Management provides resources

related to workplace safety for


There shall be

sufficient change

rooms, washrooms,

recreation rooms&

dining facilities for

nursing staff.

Self-explanatory.

b. Management shall ensure that

there is a mechanism whereby

any safety related issues are duly

reported.


c. Management shall endeavour to

promote a culture of reporting of

safety related issues such that

there is no victimization.

Self-explanatory.

This also includes

setting of a gender

harassment

committee to ensure

Self-explanatory.

18

workplace safety

from sexual

harassments.

d. A record of corrective and

preventive actions shall be

maintained wherever appropriate,

with due consideration given to

anonymity.

Self-explanatory. Self-explanatory..

Standard

NRM.9.

The organization has a documented and established grievance handling

system.


a. The organization has a well-

defined process for handling

nurse (s) grievances.


b. The nursing professionals are

educated about the mechanisms

available for addressing

grievances.


c. The head of the nursing service

protects nurse (s) rights.


d. The nursing professionals are

educated about their rights.


19

CHAPTER: 2

NURSING CARE OF PATIENT


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.

20

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.

Pain management is also addressed with a view to providing comprehensive health

care.

Empowered Nursing professionals embrace the concepts of managing patient and

nursing care situations with dignity and mutual respect which produces strong and

efficient nursing leaders within the organization thereby ensuring safe and quality

nursing care.

21

Summary of Standard

NCP.1. Nursing manual shall be established and reviewed periodically as defined by

the HCO.

NCP.2. The initial assessment shall be done by the nursing professionals in

predetermined format at prescribed time and/or as per the needs of the

patients.

NCP.3. The reassessment shall be done by the nursing professionals in

predetermined format at prescribed time.

NCP.4. For provision of nursing care, appropriate number of nursing professionals

shall be maintained as per workload.

NCP.5. The nursing care planned and provided by the nursing professionals is

recorded.

NCP.6. The nursing care is individualized to address the needs of patient and family.

NCP.7. Information is exchanged and documented during each staffing shift,

between shifts, and during transfers between units/departments.

NCP.8. There shall be established policies and protocols for vascular access

devices. (VADs)

NCP.9. The nursing care of inpatients shall be supervised by senior nursing

professionals.

NCP.10. The nursing care of vulnerable patients (elderly, children, physically and/or

mentally challenged) shall be supervised by senior nursing professionals.

NCP.11. The nursing care of patients under restraints (physical and/or chemical) shall

be supervised by senior nursing professionals.

NCP.12. Appropriate pain management practices shall be supervised by senior


NCP.13. Appropriate end of life care shall be provided to patients needing the same

by the nursing professionals.

22


Standard

NCP.1. A Nursing Manual shall be established and reviewed periodically as defined

by HCO


a. Nursing manual shall include

standard operating procedures

and guidelines for nursing care in

all settings.

Separate nursing

manual should be

prepared for all the

nursing areas like

ICU, OT, Dialysis,

ED, BMT,

Chemotherapy,

Endoscopy , Day-

care etc.

Self-explanatory.

b. Nursing manual shall also include

policy on nursing station

management.

Self-explanatory. This shall cover

Dressing trolleys

arrangement, Nurse

call system, record

maintenance, Crash

Cart arrangement.

c. Nursing manual shall contain a

master list of various forms and

formats used by nursing

professionals.


d. Nursing manual shall be available

for and followed by the nursing

professionals uniformly.


e. Nursing manual shall be reviewed Self-explanatory. Should incorporate

23

and updated regularly at least

once in annually.

changing national,

international

guidelines time to

time and GCP.

Standard

NCP.2.

The initial assessment shall be done by the nursing professionals in

predetermined format at prescribed time and/or as per the needs of the

patients.


a. Initial assessment of in-patients

includes nursing assessment

done and documented at the time

of admission.

This shall identify

the nursing needs

and also help

identify any special

needs of the patient.

It shall be

completed within a

defined time frame.

This assessment

shall help in

identifying the

nursing needs of the

patient.

A checklist or

template could be

used for the same.

b. Initial assessment includes

assessment of actual and

potential needs & problems.

This include head to

foot observation,

checking of vitals,

height, weight ,

input – output charts

24

and special needs

etc.

c. The initial nursing assessment

results in a documented nursing

care plan.

This shall be

documented by the

assigned nursing

staff in the patient

record.

For definition of

“nursing care plan”

refer to glossary.

d. The care documentation must

include preventive aspects of the

care where appropriate.

The documented

nursing care plan

should cover

preventive actions

as necessary in the

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.

This could also be

done through

booklets/patient

information leaflets

etc.

Standard

NCP.3. The reassessment shall be done by the nursing professionals in a

predetermined format at prescribed time.

25


a. Patients are reassessed at

appropriate intervals.

After the initial

assessment, the

patient is

reassessed

periodically and this

is documented in

the case sheet. The

frequency may be

different for different

areas based on the

setting and the

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.

Every patient shall

be reassessed at

least once every

shift by the caring

nurse.

Reassessments

shall be done for

day care patients

(Before discharging)

or patients awaiting

admission/ bed.

b. Patients are reassessed at the

time of receiving and transferring


26

from one unit to another.

c. Patients are also reassessed

before and after shifting for

investigations.


d. Nursing care plan is modified

when emergency situations arise.


e. Nursing professionals evaluate

outcomes using reassessment

and revise action plans as

needed.


Standard

NCP.4. For provision of nursing care, appropriate number of nursing professionals

shall be maintained as per workload.


a. Nurse patient ratio is planned and

provided based on the scope of

the unit.

The ratio should be

as per the

guidelines laid down

by Indian Nursing

Council.

Self-explanatory.

b. Nurse patient ratio is monitored in

every shift by the designated

senior nursing professionals.

Self-explanatory. Self-explanatory

c. Patient condition and nurse‟s

competency shall be considered

while assigning nursing

professionals to patient care in

each shift.

Self-explanatory.

Patient assignment

is followed where

ever possible.

Self-explanatory.

27

Standard

NCP.5. The nursing care planned and provided by the nursing professionals is

recorded.


a. Nursing professionals document

assessment, nursing activities,

and care outcomes in accurate

and timely, manner.


b. Documented information shall be

checked and supervised by the

senior nursing professionals

wherever appropriate.


c. There shall be a consistent

pattern adopted by the nursing

service for documentation of

nursing care.

Uniform pattern is

practiced across the

hospital.

Self-explanatory.

d. Adequate supervision is ensured

for the junior staff after delegating

the responsibilities.

Senior nursing

member in the

department is totally

accountable and

answerable for all

the activities of the

nursing

professionals in the

respective area.

Self-explanatory.

Standard

NCP.6. The nursing care is individualized to address the needs of patient and

28

family.


a. Nursing protocols are developed

by nursing professionals based on

current best practices and shall

focus on patient safety.


b. Assignment of patients for nursing

care is based on patient needs to

maximize the outcome.


c. Nurse use patient specific

sensitive communication and

interactive techniques to

individualize the care.

Self-explanatory Self-explanatory.

d. Care of patients is coordinated in

all care settings within the

organization.

Care of patients is

co-ordinated among

various care-

providers in a given

setting viz OPD,

emergency,IP, ICU,

etc.

The organization

shall ensure that

there is effective

communication of

patient

requirements

amongst the care-

providers in all

settings.

29

Standard

NCP.7. Information is exchanged and documented during each staffing shift,

between shifts, and during transfers between units/departments.


a. Documented information shall be

clearly dated, timed and signed by

the assigned nurse and endorsed

by the senior nursing staff at

every shift.


b. Transfers between departments/

units are done in a safe manner.

The organization

shall ensure that

intra- organization

transfers are done

adhering to safe

practices. The

patients shall be

transported in a

safe manner and a

proper handover

and takeover shall

be documented.

Standard

NCP.8. There shall be established policies and protocols for vascular access

devices. (VADs).


a. There shall be established

policies and protocols for vascular


30

access devices.

b. The nurse shall select the

appropriate type of catheter

(peripheral or central) to meet the

patient‟s vascular access needs.

Self-explanatory. This to be based on

prescribed therapy

or treatment

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

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

vascular device outside the

manufacturer‟s direction for use.


e. Vascular access bundle care (for

prevention of complications)

should be followed.

Self-explanatory. CDC guidelines can

be used as

references.

Standard

NCP.9.

The nursing care of inpatients shall be supervised by senior nursing

professionals.

31


a. A senior suitably experienced

nursing professional should guide

and supervise the nursing

professionals in each shift in each

department.

These include

Intensive care and

high dependency

units, wards,

emergency unit, and

specialized areas

like cath lab,

endoscopy, dialysis,

etc.

Self-explanatory.

b. Senior nursing professionals are

responsible for the

implementation of the policy,

protocol and procedures of the

respective areas.


c. The scope of services for senior

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

ensure availability of patients

reports in their respective records.


e. Nursing professionals seek

additional knowledge and

assistance as needed, in a timely

manner.


f. Nursing professionals recognize

any limitations to safe, competent,

and ethical care and report


32

concerns and consult and/or

initiate appropriate changes as

necessary.

g. Nursing professionals evaluate,

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.


a. There are protocols governing

care of vulnerable patient.


b. The nursing staffs are trained to

care for vulnerable patient.


c. All vulnerable patients are

identified as per HCO policy and

then assessed and reassessed

more frequently at periodic

intervals.


d. Nursing professionals monitor

vulnerable patients‟ closely

participating with the family

whenever required.


33

Standard

NCP.11.

The nursing care of patients under restraints (physical and/or chemical) shall

be supervised by senior nursing professionals.


a. These include both physical and

chemical restraint measures.


b. These patients are more

frequently monitored.


c. Staff receives training and

periodic updating in control and

management of restraint

techniques.


Standard

NCP.12. Appropriate pain management practices shall be supervised by senior



a. All patients screened for pain at

the time of admission and

reassessment of pain is done for

those patients who require pain

management.


b. Nursing professionals are trained

to identify level of pain in various

categories of patients and

document the same.


c. Nursing professionals shall Self-explanatory. Self-explanatory.

34

provide care both

pharmacological and non-

pharmacological care based on

the hospital policy.

d. The organization respects and

supports nursing management of

pain for such patients.


e. The nursing professionals

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.


a. Nursing professionals are aware

of end of life care policy of the

organization.


b. Nursing professionals shall

provide care to meet the unique

end of life care needs of the

patient and family.

Social and spiritual

needs of the family

need to be

considered.

Self-explanatory.

c. Symptomatic treatment is

provided by the nursing

professionals for all end of life

care patients with special

emphasis on alleviating pain and


35

helping them to cope

psychologically.

d. Nursing professionals are

educated and periodically trained

on end of life care.


36

CHAPTER: 3

MEDICATION OF MANAGEMENT


Designated nursing personnel shall be consulted during policy formulation pertaining to

pharmacy and management of medication. The nursing staff will ensure availability,

safe storage, administration of medications and monitoring the effects of medication.

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.

The availability of emergency medication is stressed upon. The organization should

have a mechanism to ensure that the emergency medications are standardized

throughout the organization, readily available and replenished in a timely manner. There

should be a monitoring mechanism to ensure that the required medications are always

stocked and well within expiry dates. Appropriate nursing authorities should monitor

these parameters in all areas where drugs and consumables are stored or utilized.

Every high-risk medication order should be verified by an appropriate person so as to

ensure accuracy of the dose, frequency and route of administration. The “appropriate

person” could be another doctor, trained nurse or preferably, a clinical pharmacist. Such

a person would also look for drug-drug interactions, food-drug interactions, renal or

hepatic dosing etc. There should be a mechanism by which this person could verify the

order with prescriber in case of doubts or clarifications. The verification should occur

before the medication is administered but preferably, prior to dispensing of the

medication. There should be a protocol by way of which, in case of continued conflict,

the person can approach higher authority to ensure patient safety.

37

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.

Safe use of high-risk medication like narcotics, chemotherapeutic agents and

radioactive isotopes are guided by policies and procedures.

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.

38

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


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.

39


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



a. Medication will be indented as per

HCO policy on indenting

medicines.

Nursing

professionals

should be aware of

the reorder policy of

the HCO including

for critically low

stocks.

The senior nurse in

a ward / dept.

should monitor

appropriateness of

indents whenever

generated from the

IPD or departments.

b. Medications are stored in a clean,

safe and secure environment; and

incorporating manufacturer‟s

recommendation(s).

The organization

shall also ensure

that the storage

requirements of the

drug as specified by

the manufacturer

are adhered to. This

shall be applicable

to all areas where

medications are

stored including

wards.

Medications shall be

protected from loss

Vaccines could

preferably be kept in

vaccine refrigerators

(Ice Lined

Refrigerator).

Where appropriate,

temperature

monitoring of the

storage

area/refrigerator

shall be done at

least once a day. In

case of areas which

are not open all

40

or theft. The overall

ventilation,

cleanliness of the

storage area shall

be maintained.

days, it shall be

done on all working

days.

To check for loss or

theft the

organization could

conduct audits at

regular intervals (as

defined by the

organization) to

detect such

instances.

c. Sound inventory control practices

guide storage of the medications.

Organization shall

follow or

demonstrate ABC,

VED, FSN, FIFO-

led time analysis,

etc. The medicines

shall be stored in

alphabetical or

company‟s name.

First expiry and first

Out policy should be

adhered to.

Nursing

professionals will be

trained and made

aware regarding the

need to adhere to

sound inventory

management

practices.

d. Sound-alike and look-alike

medications are identified and

stored separately.

Many drugs in

ampoules, vials or

tablets may look-

alike or sound-alike.

They should be

documented,

segregated and

The organization

can follow a method

of storing drugs by

generic name in an

alphabetical order to

address this issue.

41

stored separately at

all locations.

An effort to address

this issue should be

made while defining

the formulary and

during the

procurement of

drugs.

The list will have to

be identified at

regular intervals

depending on the

changes in the

formulary and

changes in

packaging (in case

of look-alike).

e. The list of emergency medications

is defined and is stored in a

uniform manner.

This list shall be

prepared in

consonance with

good clinical

practices and

documented. List of

drugs shall be

uniform across the

organization,

however the

quantity can differ.

A crash cart would

help the

organization to store

these medications

in a standardized

manner, i.e. the

rows and drawers

have defined

medicines.

No other drugs shall

be kept stored with

emergency

medications.

f. Emergency medications are

available all the time.

Adequate quantity

of emergency

medicines should

be stocked at all

times. Re-order

level at definite

quantity should be

clearly delineated.

Nursing staff must

know from where to

obtain emergency

medicines in the

eventuality of a

stock out during

hours when the

pharmacy / medical

stores may be

42

closed.

g. Emergency medications are

replenished in a timely manner

when used.

Self-explanatory.

An inventory check

shall be done at

least daily to ensure

this.

In case the

organization follows

a system of sealing

the emergency cart

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.


a. Nursing professionals are familiar

with the medications being used

for their patients.

E.g.

dosages, route, time,

frequency of

administration

special

precautions,

dilution

requirements,

various

administration

methods and

requirement.

Self-explanatory.

b. Prepared medication is labelled

prior to preparation of a second

Self-explanatory.

Applicable

especially for

43

drug.

parenteral drugs,

anesthetic drug

preparation in

OTs, antibiotics,

chemotherapy and

high risk drugs

c. Patient is identified prior to

administration.

Self-explanatory.

Identification shall be

done by unique

identification number

(e.g. hospital

number/IP number,

etc.) and/or name.

d. Medication is verified from the

order prior to administration.

Staff administering

medications should

go through the

treatment orders

before administration

of the medication and

then only administer

them. It is preferable

that they also check

the general

appearance of the

medication (e.g.

melting, clumping

etc.) before

dispensing.

If any of the

parameters with

respect to an order

namely name,

dose, route or

frequency/time are

missing/incomplete

the medication

administration

shall be deferred.

However, to

ensure that patient

care does not

suffer a verbal

order may be got

from the treating

doctor followed by

ratification of the

44

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

prior to administration.

Self-explanatory.

Self-explanatory.

f. Route is verified from the order


Self-explanatory.

Where applicable

the site of

administration

shall also be

verified.

g. Timing is verified from the order


Self-explanatory.

The organization

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

administration of blood and blood

products, chemotherapy and

other invasive procedure.

IPD protocols should

identify the

parameters to be

monitored during

administration of

medications.

Nursing

professionals

should be trained

to recognize alerts

for individual

medications that

45

may be used

infrequently in their

wards /

departments.

I. Medication administration is

recorded.

The organization

shall ensure that this

is done in a uniform

location and it shall

include the name of

the medication,

dosage, route of

administration, timing

and the name and

signature of the

person who has

administered the

medication.

In case of infusions,

it shall capture the

start time, the rate of

infusion and end

time.

The records shall

reflect the actual

administration. For

example, if brand

Y was given in

place of brand X

(same generically)

the documentation

shall be of brand

Y. Similarly, if the

order was for a

tablet of 250 mg

but the

administration was

½ a tablet of 500

mg the latter shall

be documented.

Standard

MOM.3.

The monitoring of patients after medication administration is supervised by

responsible personnel.


a. Monitoring of patients shall be

done after medication

Nursing

professionals

This covers drugs

including high risk

46

administration. should be familiar

with common

adverse drug

reactions of

medications.

They should know

how to recognize an

anaphylactic , any

other adverse drug

reaction and the

immediate response

required; both

therapy and

escalation.

medicines.

Senior nursing staff

should supervise

the junior nursing

professionals

involved in

monitoring critically

ill and post op

patients.

b. Monitoring of patients shall be

done after transfusion of blood

and blood products.


c. Monitoring of patients shall be

done after chemotherapy.


d. Monitoring of patients shall be

done in all post-operative cases

or where invasive procedures are

carried out.

Self-explanatory. Nursing

professionals must

be trained to carry

out a step wise de-

escalation of

monitoring

parameters based

on clinical

directions.

47

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.


a. A system shall exist to capture

near miss, medication error and

adverse drug reactions.


Nursing

professionals and

paramedical staff

should be aware of

the reporting

methods, measures

and criteria being

used by the

hospital.

b. These are reported within a

specified time frame.


c. They are collected and analysed

by appropriately trained

personnel.

Committees or

teams analysing

adverse events in

wards or related to

nursing activites

must have

representation of

senior nursing

professionals.

Self-explanatory.

48

d. Corrective and/or preventive

action(s) are taken based on the

analysis where appropriate.

A feedback

mechanism is

standardized in the

hospital.

Nursing

professionals and

paramedical staff

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.


a. The organization shall have a

policy to address verbal orders.

Self-explanatory. This will be

applicable to

doctors, nursing

professionals and

technicians

uniformly.

b. The policy shall address who can

give verbal orders and how these

orders will be validated.


c. Organization should have

approved list of drugs which can

be ordered verbally.


professionals

should be familiar

with this list.

d. No verbal orders shall be followed

except in case of emergency, or


49

as defined by organization.

e. Where verbal orders are given,

ratification shall be done at the

earliest and not later than 24 hrs.


professionals

should be

empowered to seek

endorsements by

the clinicians within

the specified

timeframe.

50

CHAPTER: 4

EDUCATION, COMMUNICATION AND GUIDANCE


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.

51

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.

52


Standard

ECG.1. The organization shall ensure that nursing professionals are trained in

communication skills.


a. There is documented evidence of

communication skills training to

nursing staff to meet the patient‟s

specific needs.


b. The communication needs of

patients who speak different

language than the care givers is

addressed.

This shall be

identified in a timely

manner and

addressed using

resources

supported by the

management.

Self-explanatory.

c. Training is imparted to address

the patient‟s needs with impaired

communication.


d. Communication skill shall be

improved periodically.


Standard

ECG.2. Nursing professionals are aware of their responsibility in protecting patient

rights.


53

a. The nursing professionals are

aware of patient rights.

The nursing

professionals are

made aware of

patient and family

rights at the time of

induction.

Self – explanatory.

b. Nursing professionals maintain

the confidentiality of patients

information.


c. Nursing professionals maintain

privacy of the patients during

care.

Self-explanatory.

Female nurse will

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.

Self-explanatory.

d. The nursing professionals support

individual patient and family

beliefs, values and customs and

involve the patient and family in

decision making processes.


54

Standard

ECG.3. Nursing professionals communicate as and when required with relevant

team members to achieve continuity of care.


a. There is a handover mechanism

among the care team across

shifts regarding patient‟s status.


b. Nursing professionals

communicate with staff in other

departments when required to

ensure that care plan is

implemented.

This shall include

relevant aspects of

care plan to

facilitate inter-

departmental

activities and avoid

delays.

This includes

patient transfers,

requisitioning

bedside services

etc.

c. HCO uses predetermined formats

for such communication wherever

required.


Standard

ECG.4. Patient and family are educated where essential and in case of any change

in nursing care plan.


a. Patient and family education

includes aspects of care plan.

This shall include

information on

relevant aspects of

care plan such as

This is documented

wherever essential.

55

safe and effective

use of medications,

food drug

interactions, diet

and nutrition,

immunisations, etc.

and preventive

aspects.

b. The education shall cover the

medical condition, pre and post-

operative education, special

procedures, preventing healthcare

associated infections, when to

seek urgent medical attention and

home care wherever applicable.

Self-explanatory. This could be done

through patient

education booklets /

videos/ leaflets, etc.

c. Nursing professionals explain to

patient/ family before any

procedures are performed on

patients.


d. Nursing professionals ensure

written informed consent

wherever essential.

This should be

ensured for all

invasive

procedures, blood

and blood product

transfusions and

prior to

administration of

anaesthesia.

Self-explanatory.

e. Patient and/or family are

educated in a language and

format that they can understand.


56

CHAPTER: 5

INFECTION CONTROL PRACTICES


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.

57

Summary of Standard

ICP.1. Infection control nurse (s)shall be designated by the organization

ICP.2. Nursing professionals shall adhere to standard precautions and hand

hygiene guidelines at all times.

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.

ICP.4. The designated nursing staff shall perform surveillance activities to capture

and monitor infection control and prevention data.

ICP.5. Isolation (barrier and reverse barrier nursing) practices shall be supervised

by senior nursing professionals.

ICP.6. Infection Control Nurse maintains records of all occupational injuries and

pre- and post-exposure prophylaxis.

58


Standard

ICP.1. Infection control nurse (s) shall be designated by the organization


a. The criteria for designating ICN

shall be based on qualification or

training.

Self-explanatory.

Ideally there should

be at least one

Infection control

Nurse for every 200

operational beds.

Self-explanatory.

b. Infection control nurse (s) shall

have specialized training (internal

or external) in hospital infection

control.


c. Infection control nurse (s) shall

have documented role and

responsibilities.

Self-explanatory. Role of ICN (s) is

identified and

commensurate with

the Infection Control

Program needs of

Healthcare

Organization.

59

Standard

ICP.2. Nursing professionals shall adhere to standard precautions and hand

hygiene guidelines at all times.


a. Nursing professionals are trained

in standard precautions and hand

hygiene guidelines.

The organization

shall adhere to

international /

national guidelines

on hand hygiene.

A good reference is

the WHO guidelines

of 2009.

The organization

could display the

necessary

instructions near

every hand washing

area.

b. Nursing professionals shall be

conversant with Personal

protective equipment (PPE) and

their use.

Self-explanatory.

They should be

available at the

point of use and the

organization shall

ensure that it

maintains an

adequate inventory.

Personal protective

equipment includes:

1. Gloves

2. protective eye

wear

(goggles)

3. Mask

4. apron

5. gown

6. boots/shoe

cover, and

7. cap/ hair

cover.

c. The organization audits

compliance to standard

precautions and hand hygiene

This shall be done

at a minimum once

every month. An

A good tool for hand

hygiene monitoring

is the WHO‟s “Hand

60

practices. appropriate sample

size shall be chosen

and all categories of

staff (involved in

direct patient care)

shall be monitored.

Hygiene Observation

Form”.

Another tool that can

be utilised is use of

Infection control

assessment tool

(ICAT).

d. The nursing staff adheres to

cleaning, disinfection and

sterilization practices.

It shall be

addressed at all

levels of the

organization, e.g.

ward and OT. It is

preferable that the

organization follows

a uniform policy

across different

departments within

the organization.

Infection control

assessment tool

(ICAT) can be

utilised for

monitoring of

sterilisation and

disinfection

practices.

e. The nursing staff adheres to safe

linen management practices.

Self-explanatory. Nursing staff is

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

safe injection practices.


g. The senior nursing professionals Self-explanatory. ICAT may be used

61

along with other professionals

identified by the HCO monitor

safe linen management practices.

for such monitoring.

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.


a. The organization ensures

provision for appropriate

biomedical waste management

practices.


b. Where applicable municipal

waste (General waste) rules shall

be complied with by the nursing

personnel.


c. Nursing professionals shall be

conversant with disposal of

Personal protective equipment

(PPE).

Self-explanatory.

Appropriate

segregation at the

point(s) of use shall

be done.

Disposal of personal

protective equipment

includes but not

limited to disposal of:

1. Gloves,

2. Protective eye

wear (goggles)

3. Mask,

4. Apron,

5. Gown,

6. Boots/shoe

cover, and

62

7. Cap/ hair cover.

Standard

ICP.4. The designated nursing staff shall perform surveillance activities to capture

and monitor infection control and prevention data.


a. Surveillance activities are

appropriately directed towards the

identified high-risk areas and

procedures.

The organization

must be able to

provide evidence of

conducting periodic

surveillance

activities in its

identified high-risk

areas and

procedures.

It shall define the

frequency and

mode of

surveillance.

The surveillance

system should be

appropriate and

adhering to national

/ international

guidelines.

Surveillance

activities include

areas where

demolition,

The organization

should use a

judicious mix of

active and passive

surveillance.

The organization

could lay down the

parameters that

need to be captured

and the process for

reporting.

HCO may use ICAT

for monitoring

service areas like

surgical units,

intensive care units

and can also be

used for monitoring

isolation

precautions, care of

devices and

catheters etc.

63

construction or

repairs are

undertaken,

especially in high

risk areas.

b. Appropriate feedback regarding

HAI rates are provided on a

regular basis to appropriate

personnel.

The feedback shall

include the rates,

trends and

opportunities for

improvement. It

could also provide

specific inputs to

reduce the HAI rate.

This could be in the

form of a

bulletin/newsletter,

or periodic circulars

and meetings.

c. The surveillance activities include

monitoring of environment and

infection control indicators.

Self-explanatory.

This includes

monitoring of SSI,

VAP, CLABSI,

CAUTI.

d. The surveillance activities include

monitoring of cleaning,

sterilization and disinfection in

patient care units.

Self-explanatory.

This includes

monitoring of

terminal cleaning

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.

64


a. The organization provides

appropriate resources for isolation

practices.

The organization

shall define the

conditions where

isolation is required

and the conditions

wherein barrier

nursing or both are

required. The same

shall be carried out.

The organization

shall ensure that it

provides the

necessary

resources to carry

out the activity (e.g.

clothing, masks,

gloves, etc.).

Refer to glossary for

“isolation/barrier

nursing”.

Ideally patients

requiring isolation

(contact, droplet

and airborne)

should be placed in

isolation rooms and

droplet cases be

kept in negative

pressure rooms. An

air-conditioned

single room with an

exhaust or a well-

ventilated room is

an adequate option

for healthcare

facilities without

“negative pressure”

rooms. If an air-

conditioned single

room is not

available, a fan can

be placed in the

room to direct

airflow towards an

outside window.

The door/s to the

65

aisle or other rooms

should be kept

closed at all times.

Appropriate signage

shall be used/

displayed.

b The Nursing professionals are

familiar with the type of isolation

(barrier and reverse barrier)

facilities provided by the HCO.


c Senior Nursing Professionals

monitor the nursing activities

provided in isolation facilities.

Self-explanatory.

This should include

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.

Self-explanatory.

Standard

ICP.6.

Infection Control Nurse maintains records of all occupational injuries and

pre- and post-exposure prophylaxis.


66

a. Hazardous materials specific to

the settings and locations that

they work in are identified by the

nursing professionals. (as

applicable).

The nursing shall

identify, list and

document the

hazardous materials

and has a

documented

procedure for their

sorting, storage,

handling,

transpirations,

disposal

mechanism, and

method for

managing spillages

and adequate

training of the

personnel for these

jobs.

The hazardous

materials include

blood, body fluids

as well as some

chemicals and

drugs like

chemotherapeutic

agents. The

hazardous materials

identified should be

specific to the work

place that they work

in and not a

generalised list of

items across the

HCO.

b. The nursing professionals

implement processes for sorting,

labeling, handling, storage,

transporting and disposal of

hazardous materials.

The organization

has ensured display

of Material Safety

Data Sheets

(MSDS) for all

hazardous materials

and has accordingly

arranged training of

personnel who

handles such

materials.

Self-explanatory.

c. The Nursing professionals are

aware of the HCOs plan for

Self-explanatory.

The organization

could have a

67

managing the spills of hazardous

materials and are able to

supervise and adequately

implement the same in their

specific locations of work.

HAZMAT kit(s) for

handling spills. The

nursing staff should

be aware of the kit

and the

methodology of use

of the kit in their

area of work.

d. Appropriate pre- and post-

exposure prophylaxis is provided

to all staff members concerned.

Self-explanatory

Infection control

Nurse maintains

documentation of all

occupational injuries

and pre- and post-

exposure

prophylaxis records.

For example,

hepatitis B

Vaccination and

immunisation status

shall be available

with designated

individuals. And

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.

68

CHAPTER: 6

EMPOWERMENT AND GOVERNANCE


The standards encourage the governance of the organization in a professional and

ethical manner. The responsibilities of all the Nursing professionals performing

management functions are defined.

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.

69

Summary of Standards

EG.1. The responsibilities of those responsible for nursing management are

defined.

EG.2.

The Head of the Nursing service ensures that suitable mechanisms exist to

govern the nursing Service.

EG.3. Nursing professionals are involved and participate in decision making related

to organization and nursing services.

EG.4. The Management empowers nursing staff

EG.5. The organization has an established process for proactive risk assessment

and error management.

EG.6. The infection control programme is supported by the management and

includes training of staff.

70


Standard

EG.1. The responsibilities of those responsible for nursing management are

defined.


a. Those responsible for nursing

management lay down the

nursing department vision.

For definition of

vision refer to

glossary.

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.

This should be part

of nursing manual,

refer NCP 1.

b. Those responsible for nursing


nursing department mission.

For definition of

mission refer to

glossary.


website would not


preferable that the

same be translated



This should be part

of nursing manual,

refer NCP 1.

c. Those responsible for nursing For definition of This should be part

71


nursing department values.

values refer to

glossary.


website would not


preferable that the

same be translated



of nursing manual,

refer NCP 1.

d. Those responsible for nursing

management establish the

nursing department organogram.

The nursing

management shall

have a well-defined

organization

structure / chart and

this shall be clearly

document the

hierarchy, line of

control, along with

the function at the

various levels.

This should be part

of nursing manual,

refer NCP 1.

Standard

EG.2.

The Head of the Nursing service ensures that suitable mechanisms exist to

govern the nursing Service.


a. There is an established head of

the nursing services.

The head of the

nursing services is

72

selected based

upon identified

criteria like

qualifications,

experience and

training received.

b. The scope of Nursing services is

defined in the nursing manual.


c. The Nursing administrative policy

and procedure is defined in the

manual and implemented.


d. The department manual shall

govern the nursing functions and

activities within the department.


e. Nursing administrative policy and

procedure is defined and

implemented.


f. Structured program exists for

enhancing clinical competency

and leadership skills of nursing

professionals.


g. The Nursing leaders are involved

in quality improvement projects

and program.


73

Standard

EG.3. Nursing professionals are involved and participate in decision making related

to organization and nursing services.


a. A Nursing Management

committee is established and it

meets periodically to oversee

Nursing related issues.

Self-explanatory.

The periodicity of

the meeting needs

to be specifically

defined by the HCO

and minutes of the

meeting are

recorded along with

the action taken

reports.

Self-explanatory.

b. Nursing professionals have

membership in various

committees as appropriate.

Self-explanatory.

Nursing

professionals shall

have representation

in Infection Control,

Grievance, Safety,

OT, Death Review

Committee, etc.

c. Nursing professionals providing

direct care are involved in action

plan development and evaluation

is based on evidence based data.


d. The organization has a

mechanism to seek feedback

from nursing professionals and

This is reviewed

and improvement

opportunities are

Self-explanatory.

74

other staff regarding the quality of

nursing care and to for evaluating

nursing satisfaction.

identified and

implemented

accordingly.

Standard

EG.4. The Management empowers nursing staff.


a. There is a policy on nursing

empowerment to ensure timely

nursing care of patients.


b. Management empowers nursing

staff by involving them in decision

making.


c. Management empowers nursing

staff by appraisal and Job

incentives, encouraging

innovation.


d. Management empowers nursing

staff by supporting education.


e. Management empowers nursing

staff by promoting interpersonal

relationships.


Standard

EG.5. The organization has an established process for proactive risk assessment

75

and error management.


a. The Nursing service has clearly

defined error prevention, error

reporting and error addressing

mechanisms and the same are

documented.


b. The Nursing professionals are

provided with adequate resources

including materials and equipment

for providing safe and efficient

nursing services.


c. The nursing structure and

processes support a culture of

patient safety.


d. The Nursing professionals are

made aware of and are trained in

code blue drills, disaster

management and emergency

situations including fire and non

fire emergencies.


e. The standards of personal health

and safety of the nursing

professionals are maintained such

that ability to practice is not

compromised.


f. There is an escalation process for

nursing professionals when


76

emergency and life threatening

situations arise.

Standard

EG.6. The infection control programme is supported by the management and

includes training of staff.


a. The management makes

available resources required for

the infection control practices.

The organization

shall ensure that the

resources required

by the personnel

should be available

in a sustained

manner. This

includes both men

and materials.

Self-explanatory.

b. The organization conducts

induction training for all staff.

There must be a

documented

evidence of

induction training for

all categories of

staff before joining

department(s)

concerned. It should

include the policies,

procedures and

practices of the

77

infection control

programme.

c. The organization conducts

appropriate “in-service” training

sessions for all staff at least once

in a year.

Self-explanatory.

Self-explanatory.

78

CHAPTER: 7

NURSING QUALITY INDICATORS


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.

Excellent nursing practice is a reflection of sound ethical standards. The registered

nurse systematically enhances the quality and effectiveness of nursing practice by

demonstrating quality, by documenting the application of the nursing process in a

responsible, accountable and ethical manner and by using quality improvement

activities to initiate changes in nursing practice and health care delivery system.

A system for monitoring and measurement of nursing quality parameters shall be

established by the organization. Statistical review and analyses of trends shall be

reviewed by the Organization in order to use these as tools to aim for excellence in

nursing care delivery and satisfaction with nursing care amongst patients, thereby

contributing to overall improvement in quality of care that every patient receives.

79

Summary of Standard

NQI.1. There is a structured quality improvement and continuous monitoring

program for nursing service.

NQI.2. The organization identifies key indicators to monitor the structures,

processes and outcomes, which are used as tools for continual improvement

for nursing service.

NQI.3. The nursing quality improvement programme is supported by the

management.

NQI.4. There is an established system for nursing audit.

NQI.5. Incidents, complaints and feedback from nursing professionals are collected

and analysed to ensure continual quality improvement.

80


Standard

NQI.1. There is a structured quality improvement and continuous monitoring

program for nursing service.


a. The quality improvement

programme is developed,

implemented and maintained by a

committee with a representative

from nursing personnel.

There is need for a

formal controlled

documentation.

This will be aligned

with the

organizations

quality improvement

program.

At minimum, a

„nursing manual‟

shall be established.

This may refer to

SOPs where

required.

b. There is a designated individual

for coordinating and implementing

the nursing quality-improvement

programme.

Self-explanatory. This individual shall

necessarily be a

senior and

experienced nursing

professional

preferably with

exposure to NABH

and Quality

standards.

c. The quality improvement

programme shall be reviewed at

periodic intervals.

Self-explanatory. It should be

reviewed and

updated atleast

once every year.

81

Standard

NQI.2. The organization identifies key indicators to monitor the structures,

processes and outcomes, which are used as tools for continual improvement

for nursing service.


a. The patient falls are monitored

and the incident of patient falls is

documented by the appropriate


The factors

responsible for

patient fall can be

classified as under:

1. Nursing related

2. Patient related-

unbalanced or

unsteady gait,

incorrect use of

equipment

3. Falls requiring

Medical

intervention

Self-explanatory.

b. The hospital acquired decubitus /

pressure ulcers in various

departments are monitored and

recorded as per laid down

protocols by the HCO.


c. The medication errors during

provisioning of care are monitored

and recorded on occurrence by

the concerned nursing staff in

forms as laid down by the HCO.


82

d. Monitoring of accidental delining

(if applicable).

Self-explanatory. Self-explanatory

e. All extravasations are recorded

and monitored as per the laid

down protocols.


f. All needle stick injuries are

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

including strangulation are

monitored and documented.


h. The hand hygiene compliance is

monitored and recorded by the

nursing professionals responsible

for the same.

Self-explanatory.

The monitoring

should be as per the

criteria identified by

the WHO guidelines

on Hand Hygiene.

Self-explanatory.

i. The compliance with pain

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

the nursing care is monitored by

the senior nursing professionals

and the same is documented.


83

Standard

NQI.3. The nursing quality improvement programme is supported by the

management.


a. The management makes

available adequate resources

required for quality improvement

programme.

This shall include

the men, material,

machine, money

and method. These

should be in steady

supply so as to

ensure that the

programme

functions smoothly.

b. The management supports and

implements use of appropriate

quality improvement, statistical

and management tools in its

quality improvement programme.

Self-explanatory. For example, Root

Cause Analysis,

FMEA, Project

Evaluation and

Review Technique

(PERT), Critical

Path Method

(CPM), Control

Charts, etc.

c. The senior nursing professionals

as delineated by the HCO also

monitor the nursing satisfaction

based on pre determined criteria

in consultation with the Human

resource department of the HCO.


84

d. The attrition rate and frequency of

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

NQI.4. There is an established system for nursing audit.


a. Nursing staff participates in

the audit.

The organization shall

identify such personnel.

It shall necessarily

include senior and junior

nursing professionals

and could be a mix of

clinicians and

administrators.

These could be

members of the

core

committee/nursing

quality assurance

committee, etc.

b. The parameters to be audited

are defined by the

organization.

As these audits are

retrospective/concurrent

in nature, it is imperative

that this be done using

predefined parameters

so that there is no bias.

The parameters could be

disease based, nursing

protocol based, nursing

The audit shall

encompass all

aspects of care

including clinical

and nursing.

85

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

maintained.

This means that the

names of the patients

and the hospital staff

who may figure in the

audit documents must

not be disclosed or any

reference be made to

them in public

discussions/conferences.

This is at the stage

of report

preparation and

dissemination. The

staff participating in

the audit shall

maintain patient

and staff anonymity

and not reveal

names.

d. All audits are recorded and

reviewed.

Self-explanatory.

The organization

could use a

checklist with the

predefined

parameters and the

audit findings could

be recorded on this

86

sheet.

e. Implementation is recorded

and reviewed.

All remedial measures

as ascertained should be

documented and

implemented and

improvements thereof

recorded to complete the

audit cycle.

This should

preferably be done

based on root-

cause analysis.

Standard

NQI.5. Incidents, complaints and feedback from nursing professionals are collected

and analysed to ensure continual quality improvement.


a. The organization has an incident

reporting system.

The incident

reporting system

includes:

i. identification

ii. reporting

iii. review

iv. action on

incidents.

While capturing the

organization shall

capture all incidents

without going into

the severity or

whether harm was

caused.

b. The organization has a process to

collect feedback and receive

complaints.

Self-explanatory. This shall be

communicated to

the patients using

displays or

brochures.

c. The organization has established The quality This could

87

processes for analysis of

incidents, feedbacks and

complaints.

improvement

committee (refer to

CQI 1a) shall be

responsible for this

activity.

preferably be done

by identifying the

root cause.

Where possible, it is

preferable that

patients be included

in analysing the

feedback and

complaint.

d. Corrective and preventive actions

are taken based on the findings of

such analysis.

The objective of this

is to continually

improve the quality

of patient-care

services.

All such action shall

be documented.

e. Feedback about care and service

is communicated to staff.

At a minimum,

patient satisfaction

levels shall be

communicated on a

monthly basis.

This could be done

using internal

communication.

It is equally

important that

positive feedback

about care and

service is

communicated to

staff.

88

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.

Certification

assessment

The evaluation process for assessing the compliance of an

organization with the applicable standards for determining its

accreditation status.

Advance life

support

Emergency medical care for sustaining life, including

defibrillation, airway management, and drugs and medications.

Adverse drug

event

Adverse event: Any untoward medical occurrence that may

present during treatment with a pharmaceutical product but

which does not necessarily have a causal relationship with this

treatment.

Adverse drug reaction: A response to a drug which is noxious

and unintended and which occurs at doses normally used in

man for prophylaxis, diagnosis, or therapy of disease or for the

modification of physiologic function.

Therefore ADR = adverse event with a causal link to a drug

Adverse drug event:The FDA 88abeling88e the term adverse

drug event to be a synonym for adverse event.

In the patient-safety literature, the terms adverse drug event and

adverse event usually denote a causal association betweenthe

drug and the event, but there is a wide spectrum of definitions

89

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”

Adverse drug events extend beyond adverse drug reactions to

include harm from overdoses and under-doses usually related to

medication errors.

A minority of adverse drug events are medication errors, and

medication errors rarely result in adverse drug events.

Adverse event An injury related to medical management, in contrast to

complications of disease. Medical management includes all

aspects of care, including diagnosis and treatment, failure to

diagnose or treat, and the systems and equipment used to

deliver care. Adverse events may be preventable or non-

preventable. (WHO Draft Guidelines for Adverse Event

Reporting and Learning Systems).

Assessment All activities including history taking, physical examination,

laboratory investigations that contribute towards determining the

prevailing clinical status of the patient.

Barrier nursing

The nursing of patients with infectious diseases in isolation to

prevent the spread of infection.

As the name implies, the aim is to erect a barrier to the passage

of infectious pathogenic organisms between the contagious

patient and other patients and staff in the hospital, and thence to

90

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

support

Basic life support (BLS) is the level of medical care which is used

for patients with life-threatening illnesses or injuries until the

patient can be given full medical care.

Bylaws

A rule governing the internal management of an organization. It

can supplement or complement the government law but cannot

countermand it, e.g. municipal bylaws for construction of

hospitals/nursing homes, for disposal of hazardous and/or

infectious waste.

Clinical audit A quality improvement process that seeks to improve patient

care and outcomes through systematic review of care against

explicit criteria and the implementation of change. (Principles for

Best Practice in Clinical Audit 2002, NICE/CHI).

Clinical practice

guidelines

Clinical practice guidelines are systematically developed

statements to assist practitioner and patient decisions about

appropriate health care for specific clinical circumstances. (Field

and Lohr 1990. Page 38).

Communication Communication is a two way process of exchange of thoughts,

messages, and information to the mutual understanding of all the

parties. It can be exchange by speech, gestures, and by the use

of writing. The parties in health care refer to the medical

professionals, the nursing professionals ,the paramedical staff,

the patients , the families of the patients, the visitors and other

stake holders viz suppliers, administrators etc.

Competence Demonstrated ability to apply knowledge and skills (para 3.9.2 of

91

ISO 9000: 2000).

Knowledge is the understanding of facts and procedures. Skill is

the ability to perform specific action. For example, a competent

gynaecologist knows about the patho-physiology of the female

genitalia and can conduct both normal as well as abnormal

deliveries.

Confidentiality

Restricted access to information to individuals who have a need,

a reason and permission for such access. It also includes an

individual‟s right to personal privacy as well as privacy of

information related to his/her healthcare records.

Consent

1. Willingness of a party to undergo examination/procedure/

treatment by a healthcare provider. It may be implied (e.g.

patient registering in OPD), expressed which may be written

or verbal. Informed consent is a type of consent in which the

healthcare provider has a duty to inform his/her patient about

the procedure, its potential risk and benefits, alternative

procedure with their risk and benefits so as to enable the

patient to take an informed decision of his/her health care.

2. In law, it means active acquiescence or silent compliance by

a person legally capable of consenting. In India, legal age of

consent is 18 years. It may be evidenced by words or acts or

by silence when silence implies concurrence. Actual or

implied consent is necessarily an element in every contract

and every agreement.

Credentialing The process of obtaining, verifying and assessing the

qualification of a healthcare provider.

Data Raw facts, clinical observations, or measurements collected

during an assessment activity.

92

Disciplinary

proceedings

Sequence of activities to be carried out when staff does not

conform to the laid-down norms, rules and regulations of the

healthcare organization.

Empowerment Empowerment is a dynamic process that results from mutual

interaction between personal and collective traits of nurses as

well as the culture and the structure of the organization. It means

to invest or to give authority to the nurses based upon their

demonstrated capabilities and competence the power to make

decisions for patient care under specific situations and

conditions.

End of life Period of time marked by disability or disease that is

progressively worse until death.

Ethics

Medical ethics is the discipline of evaluating the merits, risks,

and social concerns of activities in the field of

medicine.(en.wikipedia.org/wiki/Medical ethics)

Evidence-based

medicine

Evidence-based medicine is the conscientious, explicit, and

judicious use of current best evidence in making decisions about

the care of individual patients.

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.

Goal A broad statement describing a desired future condition or

achievement without being specific about how much and when.

(ASQ).

The term “goals” refers to a future condition or performance level

that one intends to attain. Goals can be both short- and longer-

93

term. Goals are ends that guide actions. (MBNQA)

Grievance-

handling

procedures

Sequence of activities carried out to address the grievances of

patients, visitors, relatives and staff.

Guidance The act or process of guiding someone or something.

Hazardous

materials

Substances dangerous to human and other living organisms.

They include radioactive or chemical materials.

Hazardous waste Waste materials dangerous to living organisms. Such materials

require special precautions for disposal. They include biologic

waste that can transmit disease (for example, blood, tissues)

radioactive materials, and toxic chemicals. Other examples are

infectious waste such as used needles, used bandages and fluid

soaked items.

Healthcare-

associated

infection

Healthcare-associated infections (HAIs) are infections caused by

a wide variety of common and unusual bacteria, fungi, and

viruses during the course of receiving medical care. (CDC)

This was earlier referred to as Nosocomial/hospital-acquired/

hospital-associated infection(s).

Healthcare

organization

Generic term is used to describe the various types of

organization that provide healthcare services. This includes

ambulatory care centres, hospitals, laboratories, etc.

High-

dependency unit

A high-dependency unit (HDU) is an area for patients who

require more intensive observation, treatment and nursing care

than are usually provided for in a ward. It is a standard of care

between the ward and full intensive care.

In service Organised education/training usually provided in the workplace

94

education/

training

for enhancing the skills of staff members or for teaching them

new skills relevant to their jobs/tasks.

Indicator A statistical measure of the performance of functions, systems or

processes overtime. For example, hospital acquired infection

rate, mortality rate, caesarean section rate, absence rate, etc.

Information Processed data which lends meaning to the raw data.

Intent A brief explanation of the rational, meaning and significance of

the standards laid down in a particular chapter.

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.

Isolation

Separation of an ill person who has a communicable disease

(e.g., measles, chickenpox, mumps, SARS) from those who are

healthy. Isolation prevents transmission of infection to others and

also allows the focused delivery of 94abeling94ed health care to

ill patients. The period of isolation varies from disease-to-

disease. Isolation facilities can also be extended to patients for

fulfilling their individual, unique needs.

Job description 1. It entails an explanation pertaining to duties, responsibilities

and conditions required to perform a job.

2. A summary of the most important features of a job, including

the general nature of the work performed (duties and

responsibilities) and level (i.e., skill, effort, responsibility and

working conditions) of the work performed. It typically

includes job specifications that include employee

95

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

96

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.

Multi-disciplinary A generic term which includes representatives from various

disciplines, professions or service areas.

Near-miss A near-miss is an unplanned event that did not result in injury,

illness, or damage--but had the potential to do so. (Wikipedia)

Errors that did not result in patient harm, but could have, can be

categorised as near-misses.

No harm This is used synonymously with near miss. However, some

authors draw a distinction between these two phrases.

A near-miss is defined when an error is realised just in the nick

of time and abortive action is instituted to cut short its translation.

In no harm scenario, the error is not recognised and the deed is

done but fortunately for the healthcare professional, the

expected adverse event does not occur. The distinction between

the two is important and is best exemplified by reactions to

administered drugs in allergic patients. A prophylactic injection of

cephalosporin may be stopped in time because it suddenly

transpires that the patient is known to be allergic to penicillin

(near-miss). If this vital piece of information is overlooked and

the cephalosporin administered, the patient may fortunately not

develop an anaphylactic reaction (no harm event).

Nursing Audit Nursing Audit is part of the cycle of quality assurance. It

incorporates the systematic and critical analysis by nurses,

midwives and health visitors, in conjunction with other staff, of

the planning, delivery and evaluation of nursing and midwifery

97

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).

It can also be defined as the process of collecting information

from nursing reports and other documented evidence about

patient care and assessing the quality of care by the use of

quality assurance programmes.

Nursing Care

Plan

A plan that identifies patient care needs, lists the strategy to

meet those needs, documents treatment goals and objectives,

outlines the criteria for ending interventions, and documents the

individual‟s progress in meeting specified goals and objectives.

The format of the plan may be guided by specific policies and

procedures, protocols, practice guidelines or a combination of

these. It includes preventive, promotive, curative and

rehabilitative aspects of care.

Objective A specific statement of a desired short-term condition or

achievement includes measurable end-results to be

accomplished by specific teams or individuals within time limits.

(ASQ)

Objective

element

It is that component of standard which can be measured

objectively on a rating scale. The acceptable compliance with

the measureable elements will determine the overall compliance

with the standard.

Occupational

health hazard

The hazards to which an individual is exposed during the course

of performance of his job. These include physical, chemical,

biological, mechanical and psychosocial hazards.

Patient-care The location where a patient is provided health care as per his

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setting needs, e.g. ICU, speciality ward, private ward and general ward.

Patient record/

medical record/

clinical record

A document which contains the chronological sequence of

events that a patient undergoes during his stay in the healthcare

organization. It includes demographic data of the patient,

assessment findings, diagnosis, consultations, procedures

undergone, progress notes and discharge summary. (Death

certificate, where required).

Performance

appraisal

It is the process of evaluating the performance of employees

during a defined period of time with the aim of ascertaining their

suitability for the job, potential for growth as well as determining

training needs.

Policies They are the guidelines for decision-making, e.g. admission,

discharge policies, antibiotic policy, etc.

Privileging

It is the process for authorising all medical professionals to admit

and treat patients and provide other clinical services

commensurate with their qualifications and skills.

Procedure 1. A specified way to carry out an activity or a process (Para

3.4.5 of ISO 9000: 2000).

2. A series of activities for carrying out work which when

observed by all help to ensure the maximum use of

resources and efforts to achieve the desired output.

Process A set of interrelated or interacting activities which transforms

inputs into outputs (Para 3.4.1 of ISO 9000: 2000).

Programme A sequence of activities designed to implement policies and

accomplish objectives.

Project

evaluation and

Review

PERT is a method to analyze the involved tasks in completing a

given project, especially the time needed to complete each task,

and to identify the minimum time needed to complete the total

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Technique

(PERT)

project.

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.

Protocol A plan or a set of steps to be followed in a study, an investigation

or an intervention.

Quality 1. Degree to which a set of inherent characteristics fulfil

requirements (Para 3.1.1 of ISO 9000: 2000).

Characteristics imply a distinguishing feature (Para 3.5.1 of

ISO 9000: 2000).

Requirements are a need or expectation that is stated,

generally implied or obligatory (Para 3.1.2 of ISO

9000:2000).

2. Degree of adherence to pre-established criteria or

standards.

Or

The Institute of Medicine (IOM) stated in 1990 in Medicare:

“Quality of care is the degree to which health services for

individuals and populations increase the likelihood of

desired outcomes and are consistent with current

professional knowledge” (IOM, 1990, p.21)

Quality Part of quality management focussed on providing confidence

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assurance that quality requirements will be fulfilled (Para 3.2.11 of ISO

9000:2000).

Quality

improvement

Ongoing response to quality assessment data about a service in

ways that improve the process by which services are provided to

consumers/patients.

Re-assessment It implies continuous and ongoing assessment of the patient

which is recorded in the medical records as progress notes.

Resources It implies all inputs in terms of men, material, money, machines,

minutes (time), methods, metres (space), skills, knowledge and

information that are needed for efficient and effective functioning

of an organization.

Restraints Devices used to ensure safety by restricting and controlling a

person‟s movement. Many facilities are “restraint free” or use

alternative methods to help modify behaviour.

www.alz.org/Resources/Glossary.asp. Restraint may be physical

or chemical (by use of sedatives).

Risk assessment Risk assessment is the determination of quantitative or

qualitative value of risk related to a concrete situation and a

recognised threat (also called hazard). Risk assessment is a

step in a risk management procedure. (Wikipedia)

Risk

management

Clinical and administrative activities to identify, evaluate and

reduce the risk of injury.

Risk reduction The conceptual framework of elements considered with the

possibilities to minimise vulnerabilities and disaster risks

throughout a society to avoid (prevention) or to limit (mitigation

and preparedness) the adverse impacts of hazards, within the

broad context of sustainable development [Source:

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http://www.preventionweb.net/english/ professional/terminology/].

It is the decrease in the risk of a healthcare facility, given activity,

and treatment process with respect to patient, staff, visitors and

community.

Root Cause

Analysis (RCA)

Root Cause Analysis (RCA) is a structured process that

uncovers the physical, human, and latent causes of any

undesirable event in the workplace. Root cause analysis (RCA)

is a method of problem solving that tries to identify the root

causes of faults or problems that cause operating events.

RCA practice tries to solve problems by attempting to identify

and correct the root causes of events, as opposed to simply

addressing their symptoms. By focusing correction on root

causes, problem recurrence can be prevented. The process

involves data collection; cause charting, root cause identification

and recommendation generation and implementation.

Safety The degree to which the risk of an intervention/procedure, in the

care environment is reduced for a patient, visitors and healthcare

providers.

Scope of

services

Range of clinical and supportive activities that are provided by a

healthcare organization.

Security Protection from loss, destruction, tampering, and unauthorised

access or use.

Senior Nursing

professional

The act or function of rendering advice or showing the correct

path on educational or vocational matters.

Staff All personnel working in the organization including employees,

“fee-for-service” medical professionals, part-time workers,

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contractual personnel and volunteers.

Standard

precautions

1. A method of infection control in which all human blood and

other bodily fluids are considered infectious for HIV, HBV

and other blood-borne pathogens, regardless of patient

history. It encompasses a variety of practices to prevent

occupational exposure, such as the use of personal

protective equipment (PPE), disposal of sharps and safe

housekeeping

2. A set of guidelines protecting first aiders or healthcare

professionals from pathogens. The main message is: "Don't

touch or use anything that has the victim's body fluid on it

without a barrier." It also assumes that all body fluid of a

patient is infectious, and must be treated accordingly.

Standard Precautions apply to blood, all body fluids,

secretions, and excretions (except sweat) regardless of whether

or not they contain visible blood, non-intact skin and mucous

membranes.

Standards A statement of expectation that defines the structures and

process that must be substantially in place in an organization to

enhance the quality of care.

Sterilisation It is the process of killing or removing microorganisms including

their spores by thermal, chemical or irradiation means.

Surveillance The continuous scrutiny of factors that determines the

occurrence and distribution of diseases and other conditions of ill

health. It implies watching over with great attention, authority and

often with suspicion. It requires professional analysis and

sophisticated interpretation of data leading to recommendations

for control activities.

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Transfusion

reaction

A transfusion reaction is a problem that occurs after a patient

receives a transfusion of blood.

Unstable patient A patient whose vital parameters need external assistance for

their maintenance.

Values The fundamental beliefs that drive organizational behavior and

decision making. (ASQ)

This refers to the guiding principles and behaviours that embody

how an organization and its people are expected to operate.

Values reflect and reinforce the desired culture of an

organization. (MBNQA)

Vision An overarching statement of the way, an organization wants to

be ideal state of being at a future point. (ASQ)

This refers to the desired future state of an organization. The

vision describes where the organization is headed, what it

intends to be, or how it wishes to be perceived in the future.

(MBNQA)ss

Vascular Access

Device

Catheters, tubes, or device inserted into the vascular system,

including veins, arteries, and bone marrow.

Vulnerable

patient

Those patients who are prone to injury and disease by virtue of

their age, sex, physical, mental and immunological status, e.g.

infants, elderly, physically- and mentally-challenged, those on

immunosuppressive and/or chemotherapeutic agents.

standards for nursing excellence€¦ · 3 from the nursing services. the standards are on the same...

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