National Accreditation Board For Hospitals and Healthcare Providers

STANDARDS FOR NURSING EXCELLENCE
First Edition
October 2013
NATIONAL ACCREDITATION BOARD FOR

HOSPITALS AND HEALTHCARE
PROVIDERS
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
2
from the nursing services. The Standards are on the same framework as has been for
the NABH Standards for Health Care Organizations.
The 1st edition of nursing excellence standards is divided into 07 chapters, focusing on
various professional, administrative and governance aspects of nursing. Seven chapters
are further divided into 48 standards. Put together there are 216 objective elements
incorporated within these standards. Objective elements are required to be complied
with in order to meet the requirement of a particular standard. Similarly, standards are
required to be complied with, in order to meet the requirement of a particular chapter.
Finally all chapters are deciding factor to say whether a hospital is meeting the
requirements of the certification program. In the beginning of each chapter, intent is
given to highlight the summary of the chapter. For most of the objective elements,
interpretation is provided just to further elaborate on how that objective element can be
met.
Standards are dynamic and would be under constant review process. Comments and
suggestions for improvement are appreciated. We seek your support in keeping these
standards adequate to the need of industry.
3
TABLE OF CONTENTS
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
4
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.
5
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.
6
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 It shall use recognised References may be
planning supports the methods for determining used. INC guidelines,
organization‟s current levels of nursing staffing. Acuity based norms etc.
and future ability to meet A yearly nursing plan is The organization will
the care, treatment and to be documented, with ensure that the plan
service needs of the inputs from all addresses staffing crisis
patient. stakeholders including situations due to
the Nursing Head, attrition, and the hiring
Medical Head, key plan ensures vacancies
clinicians, HR and are filled up early so that
Finance. This should be patient care is not
in line with growth compromised.
projections, strategic A contingency plan for
plans and budgets of the staffing in sudden high
hospital. In case higher occupancy levels is in
approvals are needed eg place. The deciding
in Govt sector, hospitals, parameters or
the plan approval will be guidelines for nursing
taken in advance of manpower must be
implementation. clearly delineated.
b. The organization The nursing staff should A good reference could
maintains an adequate be commensurate with be the INC guidelines.
number and mix of the workload and the
nursing staff to meet the clinical requirement of
7
care, treatment and the patients. Workload
service needs of the on Nursing professionals
patient. will be monitored.
c. The person heading the INC recognized Self-explanatory.
nursing service has qualifications with
requisite and appropriate management
qualifications. training/degree.
d. The person heading the Self-explanatory As per INC guidelines /
nursing service has MOHFW hospital
requisite and appropriate manual guidelines.
experience.
e. The required job The content of each job Refer to glossary for
specification and job should be well defined definition of "job
description are defined and the qualifications, description” and “job
for each category of skills and experience specification". For a job
nursing staff. required for performing which requires the skills
the job should be clearly of a nurse the minimum
laid down. The job qualification shall be a
description should be GNM/ B.Sc Nursing.
commensurate with the
qualification. This should be part of
nursing manual, refer
NCP 1.
Standard
NRM.2. The organization has structures and processes for induction and for
enhancing the transition of novices to competent nursing professionals.
8
a. Nursing shift plans based upon For eg. if the shift Self-explanatory.
timings of shift, day or week shall for a unit is eight
identify and depute nursing hourly then the
professionals to various areas nursing
based on their skills and professionals doing
competencies. the shift at night
should have skills
and competencies
that enable her to
independently
monitor and handle
emergency
situations.
b. Training need shall be identified Self-explanatory. Self-explanatory.
on a continual basis by the senior
nursing professionals as well as
the Clinical Heads as appropriate.
c. Required competency parameters These are generally Self-explanatory.
shall be evaluated by such senior bed-side nursing
nursing professionals and the care procedures
clinical and support service Heads and are therefore
and shall be recorded in the evaluated on a
training records as in NRM 2. continual basis. The
recording may be
done at suitable
periodic intervals.
Standard
NRM.3. The organization has processes in place for induction training, In-service
education and Continuous Nursing Education (CNE) programmes and for
9
documentation of the same in the personal files.

a. Every nurse entering the The organization The contents of this
organization is provided induction shall determine as training could be
training. to when induction provided to every
training shall be nursing staff in the
conducted. form of a booklet.
However, it shall be There can be
within 15 days of separate induction
the staff joining. training at the
The contents of the organizational level

training and for the
induction
should be defined respective
and should include departments.
issues related to
patient safety and
quality nursing care.
b. A documented training and A training manual The training shall be

development policy exists for the incorporating the for all categories of
staff. procedure for nursing staff.
identification of
training needs, the
training
methodology,
documentation of
training, training
assessment, impact
of training and the
training calendar
10
should be prepared.
c. The organization maintains The organization Where possible, the
records of training. shall maintain a contents of the
record of all training may also be
trainings provided. captured. Regular
At a minimum, it assessments of the
shall include the title effectiveness of the
of the training, the imparted training in
trainer(s), list of the respective work
trainees (with locations must be
signatures) and the carried out and
post-training records of the same
feedback. maintained.
d. Nursing professionals shall The training should
receive adequate training when focus on the revised
there is a change in job job responsibilities
responsibilities or when new as well as on the
equipment is introduced. newly introduced
equipment and
technology. In case
of new equipment,
the operating
nursing staff should
receive training on
operational as well
as daily-
maintenance
aspects.
e. All nursing staff shall be trained to Self-explanatory. Self-explanatory.
provide BLS. Nursing
professionals working in intensive
11
care/high dependency units shall
undergo training in ACLS or PALS
or NALS as applicable.
Standard
NRM.4. There is a process for credentialing and privileging of nursing professionals,

permitted to provide patient care without supervision.

a. The education, registration, This may be done
training and experience of nursing by a credentialing
staff is recorded and updated and privileging
periodically. 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, The organization Refer to Indian
regulation and the organization to identifies the Nursing Council Act,
provide patient care without individuals who 1947.
supervision are identified. have the required
qualification(s),
training and
experience to
provide patient care
in consonance with
12
the law.
c. All such information pertaining to The organization Educational
the nursing staff is appropriately shall do the same parameters are
verified when possible. by verifying the validated by
credentials from the verifying the
organization which qualification
has awarded the certificates. Training
qualification/training. is validated through
training certificates
and skill verification
on the job and
experience is
validated by way of
the records
provided by the
nurse from the
previous employers.
d. Nursing staff are granted The organization For example, an
privileges in consonance with shall lay down Infection Control
their qualification, training, parameters for Nurse should have
experience and registration. identifying as to had requisite in-
what each nurse is house/external
authorised to do. training and
It is preferable to get experience and the
the privileging done aptitude and
through a knowledge to
credentialing and perform the tasks
privileging. To be required of her.
read in conjunction
with NRM 4b
committee based on
13
pre existing criteria /
parameters.
e. The requisite services to be Self-explanatory. This could be done
provided by the nursing staff are by internal
known to them as well as the communication.
various departments/units of the
organization.
f. Nursing professionals care for Self-explanatory. The organization
patients as per their privileging. New staff members could evolve a
can be under the mechanism to
proctorship till ensure that nursing

professionals are
independent
privilege being providing only those
is
provided for each services that they
have been
staff.
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 Self-explanatory. This shall be done for all
appraisal system exists in categories of nursing
the organization for staff starting from the
nursing professionals. person heading the
nursing and including
nursing professionals
who are employees.
14
For definition of
“performance appraisal”
refer to glossary.
b. The nursing professionals Self-explanatory. This could be

are made aware of the incorporated in the
system of appraisal at the service booklet and
time of induction. included in the induction
training.
c. Performance is evaluated Self-explanatory. Key result areas are
for identified
based on the pre- The for each
criteria
determined criteria. assessment should be nursing staff and training
defined and known to need assessment is also
the nursing done at the time of
professionals. It is assessment.
preferable to have
objective criteria that
can be supplemented
by subjective remarks.
d. Performance appraisal is Self-explanatory. This shall be done at
carried out at pre-defined least once a year.
intervals and is recorded.
Standard
NRM.6. There is a provision for acknowledging outstanding performances/

contributions of nursing professionals.
15
a. Patients, families and staff shall Self-explanatory. Self-explanatory.
be encouraged to report positive
feedback about nursing care
delivered in relevant areas.
b. Nursing staff with managerial Self-explanatory. Self-explanatory.
responsibilities shall ensure that
soft skills in nursing, qualities of
leadership and professional
competence are duly reported to
higher authorities. This shall be
recorded (see NRM 4 c also).
Standard
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 Appearance, Self-explanatory.
monitoring of appearance and Behaviour,
ability to impart nursing care. Communication, and
Decorum.
b. The process shall include analysis Self-explanatory. The process shall
of all complaints pertaining to ensure that there is
nursing services specifically no victimization and
addressing individual nursing corrective action is
staff. focused against the
system rather than
the individual.
c. The disciplinary policy and Self-explanatory. Principles of natural
16
procedure is based on the justice shall be
principles of natural justice. followed to ensure
that a nursing staff
against whom there
is a complaint, of
any sort, has the
right to explain
himself/herself.
Standard
NRM.8. The organization demonstrates workplace safety for nursing professionals

(including change rooms, washrooms & dining facilities).

a. Management provides resources There shall be Self-explanatory.
related to workplace safety for sufficient change
nursing professionals. rooms, washrooms,
recreation rooms&
dining facilities for
nursing staff.
b. Management shall ensure that Self-explanatory. Self-explanatory.
there is a mechanism whereby
any safety related issues are duly
reported.
c. Management shall endeavour to Self-explanatory. Self-explanatory.
promote a culture of reporting of This also includes
safety related issues such that setting of a gender
there is no victimization. harassment
committee to ensure
17
workplace safety
from sexual
harassments.
d. A record of corrective and Self-explanatory. Self-explanatory..
preventive actions shall be
maintained wherever appropriate,
with due consideration given to
anonymity.
Standard
NRM.9. The organization has a documented and established grievance handling

system.

a. The organization has a well- Self-explanatory. Self-explanatory.
defined process for handling
nurse (s) grievances.
b. The nursing professionals are Self-explanatory. Self-explanatory.
educated about the mechanisms
available for addressing
grievances.
c. The head of the nursing service Self-explanatory. Self-explanatory.
protects nurse (s) rights.
d. The nursing professionals are Self-explanatory. Self-explanatory.
educated about their rights.
18
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.
19
A designated senior nursing professional controls the care of vulnerable patients
(elderly, physically and/or mentally-challenged and children), patients undergoing
moderate sedation, patients under restraints, and end of life care.
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.
20
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
nursing professionals.
NCP.13. Appropriate end of life care shall be provided to patients needing the same
by the nursing professionals.
21
Standard
NCP.1. A Nursing Manual shall be established and reviewed periodically as defined

by HCO

a. Nursing manual shall include Separate nursing Self-explanatory.
standard operating procedures manual should be
and guidelines for nursing care in prepared for all the
all settings. nursing areas like
ICU, OT, Dialysis,
ED, BMT,
Chemotherapy,
Endoscopy , Day-
care etc.
b. Nursing manual shall also include Self-explanatory. This shall cover
policy on nursing station Dressing trolleys
management. arrangement, Nurse
call system, record
maintenance, Crash
Cart arrangement.
c. Nursing manual shall contain a Self-explanatory. Self-explanatory.
master list of various forms and
formats used by nursing
professionals.
d. Nursing manual shall be available Self-explanatory. Self-explanatory.
for and followed by the nursing
professionals uniformly.
e. Nursing manual shall be reviewed Self-explanatory. Should incorporate
22
and updated regularly at least changing national,
once in annually. 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 This shall identify A checklist or
includes nursing assessment the nursing needs template could be
done and documented at the time and also help used for the same.
of admission. 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.
b. Initial assessment includes This include head to
assessment of actual and foot observation,
potential needs & problems. checking of vitals,
height, weight ,
input – output charts
23
and special needs
etc.
c. The initial nursing assessment This shall be For definition of
results in a documented nursing documented by the “nursing care plan”
care plan. assigned nursing refer to glossary.
staff in the patient
record.
d. The care documentation must The documented This could also be
include preventive aspects of the nursing care plan done through
care where appropriate. should cover booklets/patient
preventive actions information leaflets
as necessary in the etc.
case and could
include diet, drugs,
etc.
In conditions where
it is not possible to
incorporate this at
the time of
assessment (e.g.
diagnosis not made/
unclear) the same
shall be done as
soon as a definite
diagnosis is arrived
at.
Standard
NCP.3. The reassessment shall be done by the nursing professionals in a

predetermined format at prescribed time.
24
a. Patients are reassessed at After the initial Every patient shall
appropriate intervals. assessment, the be reassessed at
patient is least once every
reassessed shift by the caring
periodically and this nurse.
is documented in Reassessments
the case sheet. The shall be done for
frequency may be day care patients
different for different (Before discharging)
areas based on the or patients awaiting
setting and the admission/ bed.
patient‟s clinical
condition and
requirements, e.g.
patients in ICU and
ER need to be
reassessed more
frequently
compared to a
patient in the ward.
Reassessments
shall also be done
in response to
significant changes
in patient‟s
condition.
b. Patients are reassessed at the Self-explanatory. Self-explanatory.
time of receiving and transferring
25
from one unit to another.
c. Patients are also reassessed Self-explanatory. Self-explanatory.
before and after shifting for
investigations.
d. Nursing care plan is modified Self-explanatory. Self-explanatory.
when emergency situations arise.
e. Nursing professionals evaluate Self-explanatory. Self-explanatory.
outcomes using reassessment
and revise action plans as
needed.
Standard
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 The ratio should be Self-explanatory.
provided based on the scope of as per the
the unit. guidelines laid down
by Indian Nursing
Council.
b. Nurse patient ratio is monitored in Self-explanatory. Self-explanatory
every shift by the designated
senior nursing professionals.
c. Patient condition and nurse‟s Self-explanatory. Self-explanatory.
competency shall be considered Patient assignment
while assigning nursing is followed where
professionals to patient care in ever possible.
each shift.
26
Standard
NCP.5. The nursing care planned and provided by the nursing professionals is
recorded.

a. Nursing professionals document Self-explanatory. Self-explanatory.
assessment, nursing activities,
and care outcomes in accurate
and timely, manner.
b. Documented information shall be Self-explanatory. Self-explanatory.
checked and supervised by the
senior nursing professionals
wherever appropriate.
c. There shall be a consistent Uniform pattern is Self-explanatory.
pattern adopted by the nursing practiced across the
service for documentation of hospital.
nursing care.
d. Adequate supervision is ensured Senior nursing Self-explanatory.
for the junior staff after delegating member in the
the responsibilities. department is totally
accountable and
answerable for all
the activities of the
nursing
professionals in the
respective area.
Standard
NCP.6. The nursing care is individualized to address the needs of patient and
27
family.

a. Nursing protocols are developed Self-explanatory. Self-explanatory.
by nursing professionals based on
current best practices and shall
focus on patient safety.
b. Assignment of patients for nursing Self-explanatory. Self-explanatory.
care is based on patient needs to
maximize the outcome.
c. Nurse use patient specific Self-explanatory Self-explanatory.
sensitive communication and
interactive techniques to
individualize the care.
d. Care of patients is coordinated in Care of patients is
all care settings within the co-ordinated among
organization. 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.
28
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 Self-explanatory. Self-explanatory.
clearly dated, timed and signed by
the assigned nurse and endorsed
by the senior nursing staff at
every shift.
b. Transfers between departments/ The organization
units are done in a safe manner. 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 Self-explanatory. Self-explanatory.
policies and protocols for vascular
29
access devices.
b. The nurse shall select the Self-explanatory. This to be based on
appropriate type of catheter prescribed therapy
(peripheral or central) to meet the or treatment
patient‟s vascular access needs. regimen, length of
treatment, duration
of dwell, vascular
integrity, patient
preference, and
ability and resource
available to care for
the device.
c. The catheter selected shall be of Self-explanatory. Self-explanatory.
the appropriate gauge and length
with the fewest number of lumen
and shall be the least invasive
device needed to accommodate
and manage the prescribed
therapy.
d. The nurse shall not alter the Self-explanatory. Self-explanatory.
vascular device outside the
manufacturer‟s direction for use.
e. Vascular access bundle care (for Self-explanatory. CDC guidelines can
prevention of complications) be used as
should be followed. references.
Standard
NCP.9. The nursing care of inpatients shall be supervised by senior nursing

professionals.
30
a. A senior suitably experienced These include Self-explanatory.
nursing professional should guide Intensive care and
and supervise the nursing high dependency
professionals in each shift in each units, wards,
department. emergency unit, and
specialized areas
like cath lab,
endoscopy, dialysis,
etc.
b. Senior nursing professionals are Self-explanatory. Self-explanatory.
responsible for the
implementation of the policy,
protocol and procedures of the
respective areas.
c. The scope of services for senior Self-explanatory. Self-explanatory.
nursing professionals includes
supervision and monitoring of all
nursing activities related to patient
safety, quality of nursing care
rendered and turnaround time.
d. The nursing professionals should Self-explanatory. Self-explanatory.
ensure availability of patients
reports in their respective records.
e. Nursing professionals seek Self-explanatory. Self-explanatory.
additional knowledge and
assistance as needed, in a timely
manner.
f. Nursing professionals recognize Self-explanatory. Self-explanatory.
any limitations to safe, competent,
and ethical care and report
31
concerns and consult and/or
initiate appropriate changes as
necessary.
g. Nursing professionals evaluate, Self-explanatory. Self-explanatory.
disseminate, and support the
integration of evidence based
practice findings into practice.
Standard
NCP.10. The nursing care of vulnerable patients (elderly, children, physically and/or
mentally challenged) shall be supervised by senior nursing professionals.

a. There are protocols governing Self-explanatory. Self-explanatory.
care of vulnerable patient.
b. The nursing staffs are trained to Self-explanatory. Self-explanatory.
care for vulnerable patient.
c. All vulnerable patients are Self-explanatory. Self-explanatory.
identified as per HCO policy and
then assessed and reassessed
more frequently at periodic
intervals.
d. Nursing professionals monitor Self-explanatory. Self-explanatory.
vulnerable patients‟ closely
participating with the family
whenever required.
32
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 Self-explanatory. Self-explanatory.
chemical restraint measures.
b. These patients are more Self-explanatory. Self-explanatory.
frequently monitored.
c. Staff receives training and Self-explanatory. Self-explanatory.
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 Self-explanatory. Self-explanatory.
the time of admission and
reassessment of pain is done for
those patients who require pain
management.
b. Nursing professionals are trained Self-explanatory. Self-explanatory.
to identify level of pain in various
categories of patients and
document the same.
c. Nursing professionals shall Self-explanatory. Self-explanatory.
33
provide care both
pharmacological and non-
pharmacological care based on
the hospital policy.
d. The organization respects and Self-explanatory. Self-explanatory.
supports nursing management of
pain for such patients.
e. The nursing professionals Self-explanatory. Self-explanatory.
educate the patient and their
family on various pain
management techniques
wherever appropriate.
Standard
NCP.13. Appropriate end of life care shall be provided to patients needing the same
by the nursing professionals.

a. Nursing professionals are aware Self-explanatory. Self-explanatory.
of end of life care policy of the
organization.
b. Nursing professionals shall Social and spiritual Self-explanatory.
provide care to meet the unique needs of the family
end of life care needs of the need to be
patient and family. considered.
c. Symptomatic treatment is Self-explanatory. Self-explanatory.
provided by the nursing
professionals for all end of life
care patients with special
emphasis on alleviating pain and
34
helping them to cope
psychologically.
d. Nursing professionals are Self-explanatory. Self-explanatory.
educated and periodically trained
on end of life care.
35
CHAPTER: 3
MEDICATION OF MANAGEMENT
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.
36
The process also includes monitoring of patients after administration and procedures for
reporting and analyzing medication errors. Process should include duration of
monitoring after administration of high alert medication and medication used for
managing pain.
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.
37
Summary of standards
MOM.1. Indenting of required medication and stores will be done and supervised by
nursing staff made responsible for this function. Storage of medication in
the wards and other therapeutic areas shall be supervised by responsible
MOM.2. The dispensing, administration and accounting of medicines shall be carried
out by the concerned personnel and should be appropriately supervised by
senior nursing staff.
MOM.3. The monitoring of patients after medication administration is supervised by
responsible personnel.
MOM.4. The nursing professionals must report near misses, medication errors and
adverse drug events as per the policy of the HCO for analysis by the
appropriate staff predefined and identified by the HCO. Feedback is
provided to staff which includes the results of analysis and recommended
preventive measures for implementation by the nursing staff wherever
appropriate.
MOM.5. The organization shall ensure that it has a policy on verbal orders which will
be applicable to doctors, nursing professionals and technicians uniformly.
38
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 Nursing The senior nurse in
HCO policy on indenting professionals a ward / dept.
medicines. should be aware of should monitor
the reorder policy of appropriateness of
the HCO including indents whenever
for critically low generated from the
stocks. IPD or departments.
b. Medications are stored in a clean, The organization Vaccines could
safe and secure environment; and shall also ensure preferably be kept in
incorporating manufacturer‟s that the storage vaccine refrigerators
recommendation(s). requirements of the (Ice Lined
drug as specified by Refrigerator).
the manufacturer Where appropriate,
are adhered to. This temperature
shall be applicable monitoring of the
to all areas where storage
medications are area/refrigerator
stored including shall be done at
wards. least once a day. In
Medications shall be case of areas which
protected from loss are not open all
39
or theft. The overall days, it shall be
ventilation, done on all working
cleanliness of the days.
storage area shall To check for loss or
be maintained. theft the
organization could
conduct audits at
regular intervals (as
defined by the
organization) to
detect such
instances.
c. Sound inventory control practices Organization shall Nursing
guide storage of the medications. follow or professionals will be
demonstrate ABC, trained and made
VED, FSN, FIFO- aware regarding the
led time analysis, need to adhere to
etc. The medicines sound inventory
shall be stored in management
alphabetical or practices.
company‟s name.
First expiry and first
Out policy should be
adhered to.
d. Sound-alike and look-alike Many drugs in The organization
medications are identified and ampoules, vials or can follow a method
stored separately. tablets may look- of storing drugs by
alike or sound-alike. generic name in an
They should be alphabetical order to
documented, address this issue.
segregated and
40
stored separately at The list will have to
all locations. be identified at
An effort to address regular intervals
this issue should be depending on the
made while defining changes in the
the formulary and formulary and
during the changes in
procurement of packaging (in case
drugs. of look-alike).
e. The list of emergency medications This list shall be A crash cart would
is defined and is stored in a prepared in help the
uniform manner. consonance with organization to store
good clinical these medications
practices and in a standardized
documented. List of manner, i.e. the
drugs shall be rows and drawers
uniform across the have defined
organization, medicines.
however the No other drugs shall
quantity can differ. be kept stored with
emergency
medications.
f. Emergency medications are Adequate quantity Nursing staff must
available all the time. of emergency know from where to
medicines should obtain emergency
be stocked at all medicines in the
times. Re-order eventuality of a
level at definite stock out during
quantity should be hours when the
clearly delineated. pharmacy / medical
stores may be
41
closed.
g. Emergency medications are Self-explanatory. In case the
replenished in a timely manner An inventory check organization follows
when used. shall be done at a system of sealing
least daily to ensure the emergency cart
this. then the check shall
be carried out
before re-sealing
every time.
Standard
MOM.2. The dispensing, administration and accounting of medicines shall be carried
out by the concerned personnel and should be appropriately supervised by
senior nursing staff.

a. Nursing professionals are familiar E.g. Self-explanatory.
with the medications being used dosages, route, time,
for their patients. frequency of
administration
special
precautions,
dilution
requirements,
various
administration
methods and
requirement.
b. Prepared medication is labelled Self-explanatory. Applicable
prior to preparation of a second especially for
42
drug. parenteral drugs,
anesthetic drug
preparation in
OTs, antibiotics,
chemotherapy and
high risk drugs
c. Patient is identified prior to Self-explanatory.
administration. Identification shall be
done by unique
identification number
(e.g. hospital
number/IP number,
etc.) and/or name.
d. Medication is verified from the Staff administering If any of the
order prior to administration. medications should parameters with
go through the respect to an order
treatment orders namely name,
before administration dose, route or
of the medication and frequency/time are
then only administer missing/incomplete
them. It is preferable the medication
that they also check administration
the general shall be deferred.
appearance of the However, to
medication (e.g. ensure that patient
melting, clumping care does not
etc.) before suffer a verbal
dispensing. order may be got
from the treating
doctor followed by
ratification of the
43
same (refer to
MOM 4i).
In case of high risk
medication(s), the
verification shall be
done by at least
two staff (nurse-
nurse or nurse-
doctor)
independently and
documented.
e. Dosage is verified from the order Self-explanatory. Self-explanatory.
prior to administration.
f. Route is verified from the order Self-explanatory. Where applicable
prior to administration. the site of
administration
shall also be
verified.
g. Timing is verified from the order Self-explanatory. The organization
prior to administration. needs to define the
timing of
administration of
medications. For
example, o.d, b.i.d,
t.i.d, q.i.d, h.s.
h. Patient is monitored during the IPD protocols should Nursing
administration of blood and blood identify the professionals
products, chemotherapy and parameters to be should be trained
other invasive procedure. monitored during to recognize alerts
administration of for individual
medications. medications that
44
may be used
infrequently in their
wards /
departments.
I. Medication administration is The organization The records shall
recorded. shall ensure that this reflect the actual
is done in a uniform administration. For
location and it shall example, if brand
include the name of Y was given in
the medication, place of brand X
dosage, route of (same generically)
administration, timing the documentation
and the name and shall be of brand
signature of the Y. Similarly, if the
person who has order was for a
administered the tablet of 250 mg
medication. but the
In case of infusions, administration was
it shall capture the ½ a tablet of 500
start time, the rate of mg the latter shall
infusion and end be documented.
time.
Standard
MOM.3. The monitoring of patients after medication administration is supervised by
responsible personnel.

a. Monitoring of patients shall be Nursing This covers drugs
done after medication professionals including high risk
45
administration. should be familiar medicines.
with common Senior nursing staff
adverse drug should supervise
reactions of the junior nursing
medications. professionals
They should know involved in
how to recognize an monitoring critically
anaphylactic , any ill and post op
other adverse drug patients.
reaction and the
immediate response
required; both
therapy and
escalation.
b. Monitoring of patients shall be Self-explanatory. Self-explanatory.
done after transfusion of blood
and blood products.
c. Monitoring of patients shall be Self-explanatory. Self-explanatory.
done after chemotherapy.
d. Monitoring of patients shall be Self-explanatory. Nursing
done in all post-operative cases professionals must
or where invasive procedures are be trained to carry
carried out. out a step wise de-
escalation of
monitoring
parameters based
on clinical
directions.
46
Standard
MOM.4. The nursing professionals must report near misses, medication errors and
adverse drug events as per the policy of the HCO for analysis by the
appropriate staff predefined and identified by the HCO. Feedback is provided
to staff which includes the results of analysis and recommended preventive
measures for implementation by the nursing staff wherever appropriate.

a. A system shall exist to capture Self-explanatory. Self-explanatory.
near miss, medication error and
Nursing
adverse drug reactions.
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 Self-explanatory. Self-explanatory.
specified time frame.
c. They are collected and analysed Committees or Self-explanatory.
by appropriately trained teams analysing
personnel. adverse events in
wards or related to
nursing activites
must have
representation of
senior nursing
professionals.
47
d. Corrective and/or preventive A feedback Nursing
action(s) are taken based on the mechanism is professionals and
analysis where appropriate. standardized in the paramedical staff
hospital. are aware of the
feedback
mechanism and
acknowledge the
feedback
appropriately.
Standard
MOM.5. The organization shall ensure that it has a policy on verbal orders which will
be applicable to doctors, nursing professionals and technicians uniformly.

a. The organization shall have a Self-explanatory. This will be
policy to address verbal orders. applicable to
doctors, nursing
professionals and
technicians
uniformly.
b. The policy shall address who can Self-explanatory. Self-explanatory.
give verbal orders and how these
orders will be validated.
c. Organization should have Self-explanatory. Nursing
approved list of drugs which can professionals
be ordered verbally. should be familiar
with this list.
d. No verbal orders shall be followed Self-explanatory. Self-explanatory.
except in case of emergency, or
48
as defined by organization.
e. Where verbal orders are given, Self-explanatory. Nursing
ratification shall be done at the professionals
earliest and not later than 24 hrs. should be
empowered to seek
endorsements by
the clinicians within
the specified
timeframe.
49
CHAPTER: 4
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.
50
Summary of standard
ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.
ECG.2. Nursing professionals shall maintain confidentiality of all patient information.
ECG.3. Nursing professionals communicate with patient, family and relevant team
members to reflect continuity of care as and when required.
ECG.4. Patient and family are educated where essential and in case of any change
in nursing care plan.
51
Standard
ECG.1. The organization shall ensure that nursing professionals are trained in
communication skills.

a. There is documented evidence of Self-explanatory. Self-explanatory.
communication skills training to
nursing staff to meet the patient‟s
specific needs.
b. The communication needs of This shall be Self-explanatory.
patients who speak different identified in a timely
language than the care givers is manner and
addressed. addressed using
resources
supported by the
management.
c. Training is imparted to address Self-explanatory. Self-explanatory.
the patient‟s needs with impaired
communication.
d. Communication skill shall be Self-explanatory. Self-explanatory.
improved periodically.
Standard
ECG.2. Nursing professionals are aware of their responsibility in protecting patient

rights.
52
a. The nursing professionals are The nursing Self – explanatory.
aware of patient rights. professionals are
made aware of
patient and family
rights at the time of
induction.
b. Nursing professionals maintain Self-explanatory. Self-explanatory.
the confidentiality of patients
information.
c. Nursing professionals maintain Self-explanatory. Self-explanatory.
privacy of the patients during Female nurse will
care. give care to male
patient only if
another female staff
or family member is
present. Same
holds true vice
versa for male
patient. The same
holds true when a
male nurse provides
care for a female
patient.
d. The nursing professionals support Self-explanatory. Self-explanatory.
individual patient and family
beliefs, values and customs and
involve the patient and family in
decision making processes.
53
Standard
ECG.3. Nursing professionals communicate as and when required with relevant

team members to achieve continuity of care.

a. There is a handover mechanism Self-explanatory. Self-explanatory.
among the care team across
shifts regarding patient‟s status.
b. Nursing professionals This shall include This includes
communicate with staff in other relevant aspects of patient transfers,
departments when required to care plan to requisitioning
ensure that care plan is facilitate inter- bedside services
implemented. departmental etc.
activities and avoid
delays.
c. HCO uses predetermined formats Self-explanatory. Self-explanatory.
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 This shall include This is documented
includes aspects of care plan. information on wherever essential.
relevant aspects of
care plan such as
54
safe and effective
use of medications,
food drug
interactions, diet
and nutrition,
immunisations, etc.
and preventive
aspects.
b. The education shall cover the Self-explanatory. This could be done
medical condition, pre and post- through patient
operative education, special education booklets /
procedures, preventing healthcare videos/ leaflets, etc.
associated infections, when to
seek urgent medical attention and
home care wherever applicable.
c. Nursing professionals explain to Self-explanatory. Self-explanatory.
patient/ family before any
procedures are performed on
patients.
d. Nursing professionals ensure This should be Self-explanatory.
written informed consent ensured for all
wherever essential. invasive
procedures, blood
and blood product
transfusions and
prior to
administration of
anaesthesia.
e. Patient and/or family are Self-explanatory. Self-explanatory.
educated in a language and
format that they can understand.
55
CHAPTER: 5
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.
56
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.
57
Standard
ICP.1. Infection control nurse (s) shall be designated by the organization

a. The criteria for designating ICN Self-explanatory. Self-explanatory.
shall be based on qualification or Ideally there should
training. be at least one
Infection control
Nurse for every 200
operational beds.
b. Infection control nurse (s) shall Self-explanatory. Self-explanatory.
have specialized training (internal
or external) in hospital infection
control.
c. Infection control nurse (s) shall Self-explanatory. Role of ICN (s) is
have documented role and identified and
responsibilities. commensurate with
the Infection Control
Program needs of
Healthcare
Organization.
58
Standard
ICP.2. Nursing professionals shall adhere to standard precautions and hand

hygiene guidelines at all times.

a. Nursing professionals are trained The organization A good reference is
in standard precautions and hand shall adhere to the WHO guidelines
hygiene guidelines. international / of 2009.
national guidelines The organization
on hand hygiene. could display the
necessary
instructions near
every hand washing
area.
b. Nursing professionals shall be Self-explanatory. Personal protective
conversant with Personal They should be equipment includes:
protective equipment (PPE) and available at the 1. Gloves
their use. point of use and the 2. protective eye
organization shall wear
ensure that it (goggles)
maintains an 3. Mask
adequate inventory. 4. apron
5. gown
6. boots/shoe
cover, and
7. cap/ hair
cover.
c. The organization audits This shall be done A good tool for hand
compliance to standard at a minimum once hygiene monitoring
precautions and hand hygiene every month. An is the WHO‟s “Hand
59
practices. appropriate sample Hygiene Observation
size shall be chosen Form”.
and all categories of Another tool that can
staff (involved in be utilised is use of
direct patient care) Infection control
shall be monitored. assessment tool
(ICAT).
d. The nursing staff adheres to It shall be Infection control
cleaning, disinfection and addressed at all assessment tool
sterilization practices. levels of the (ICAT) can be
organization, e.g. utilised for
ward and OT. It is monitoring of
preferable that the sterilisation and
organization follows disinfection
a uniform policy practices.
across different
departments within
the organization.
e. The nursing staff adheres to safe Self-explanatory. Nursing staff is
linen management practices. aware and use
appropriate PPE
while handling dirty
and soiled linen.
Nursing staff is
aware of safe
storage and
transport of used
linen.
f. The nursing staff adheres to the Self-explanatory. Self-explanatory.
safe injection practices.
g. The senior nursing professionals Self-explanatory. ICAT may be used
60
along with other professionals for such monitoring.
identified by the HCO monitor
safe linen management practices.
Standard
ICP.3. The nursing professionals shall adhere to handling, storage and disposal of
bio medical waste as per the bio medical waste management Act, 1998.

a. The organization ensures Self-explanatory. Self-explanatory.
provision for appropriate
biomedical waste management
practices.
b. Where applicable municipal Self-explanatory. Self-explanatory.
waste (General waste) rules shall
be complied with by the nursing
personnel.
c. Nursing professionals shall be Self-explanatory. Disposal of personal
conversant with disposal of Appropriate protective equipment
Personal protective equipment segregation at the includes but not
(PPE). point(s) of use shall limited to disposal of:
be done. 1. Gloves,
2. Protective eye
wear (goggles)
3. Mask,
4. Apron,
5. Gown,
6. Boots/shoe
cover, and
61
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 The organization The organization
appropriately directed towards the must be able to should use a
identified high-risk areas and provide evidence of judicious mix of
procedures. conducting periodic active and passive
surveillance surveillance.
activities in its The organization
identified high-risk could lay down the
areas and parameters that
procedures. need to be captured
It shall define the and the process for
frequency and reporting.
mode of HCO may use ICAT
surveillance. for monitoring
The surveillance service areas like
system should be surgical units,
appropriate and intensive care units
adhering to national and can also be
/ international used for monitoring
guidelines. isolation
Surveillance precautions, care of
activities include devices and
areas where catheters etc.
demolition,
62
construction or
repairs are
undertaken,
especially in high
risk areas.
b. Appropriate feedback regarding The feedback shall This could be in the
HAI rates are provided on a include the rates, form of a
regular basis to appropriate trends and bulletin/newsletter,
personnel. opportunities for or periodic circulars
improvement. It and meetings.
could also provide
specific inputs to
reduce the HAI rate.
c. The surveillance activities include Self-explanatory. This includes
monitoring of environment and monitoring of SSI,
infection control indicators. VAP, CLABSI,
CAUTI.
d. The surveillance activities include Self-explanatory. This includes
monitoring of cleaning, monitoring of
sterilization and disinfection in terminal cleaning
patient care units. procedures,
monitoring efficacy
of disinfectants in
use through
appropriate
measure.
Standard
ICP.5. Isolation (barrier and reverse barrier nursing) practices shall be supervised
by senior nursing professionals.
63
a. The organization provides The organization Refer to glossary for
appropriate resources for isolation shall define the “isolation/barrier
practices. conditions where nursing”.
isolation is required Ideally patients
and the conditions requiring isolation
wherein barrier (contact, droplet
nursing or both are and airborne)
required. The same should be placed in

shall be carried out. isolation rooms and
The organization droplet cases be
shall ensure that it kept in negative
provides the pressure rooms. An
necessary air-conditioned
resources to carry single room with an

out the activity (e.g. exhaust or a well-
clothing, masks, ventilated room is
gloves, etc.). 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
64
aisle or other rooms
should be kept
closed at all times.
Appropriate signage
shall be used/
displayed.
b The Nursing professionals are Self-explanatory. Self-explanatory.
familiar with the type of isolation
(barrier and reverse barrier)
facilities provided by the HCO.
c Senior Nursing Professionals Self-explanatory. Self-explanatory.
monitor the nursing activities This should include
provided in isolation facilities. monitoring of
standard
precautions,
disinfection and
sterilization of the
facility and
earmarking of
specific and trained
nursing staff for
carrying out duties
in such facilities.
Standard
ICP.6. Infection Control Nurse maintains records of all occupational injuries and
pre- and post-exposure prophylaxis.
65
a. Hazardous materials specific to The nursing shall The hazardous
the settings and locations that identify, list and materials include
they work in are identified by the document the blood, body fluids
nursing professionals. (as hazardous materials as well as some
applicable). and has a chemicals and
documented drugs like
procedure for their chemotherapeutic
sorting, storage, agents. The
handling, hazardous materials
transpirations, identified should be
disposal specific to the work
mechanism, and place that they work
method for in and not a
managing spillages generalised list of
and adequate items across the
training of the HCO.
personnel for these
jobs.
b. The nursing professionals The organization Self-explanatory.
implement processes for sorting, has ensured display
labeling, handling, storage, of Material Safety
transporting and disposal of Data Sheets
hazardous materials. (MSDS) for all
hazardous materials
and has accordingly
arranged training of
personnel who
handles such
materials.
c. The Nursing professionals are Self-explanatory. The organization
aware of the HCOs plan for could have a
66
managing the spills of hazardous HAZMAT kit(s) for
materials and are able to handling spills. The
supervise and adequately nursing staff should
implement the same in their be aware of the kit
specific locations of work. and the
methodology of use
of the kit in their
area of work.
d. Appropriate pre- and post- Self-explanatory For example,
exposure prophylaxis is provided Infection control hepatitis B
to all staff members concerned. Nurse maintains Vaccination and
documentation of all immunisation status
occupational injuries shall be available
and pre- and post- with designated
exposure individuals. And
prophylaxis records. PEP (e.g. Hepatitis
B immunoglobulin,
anti-retroviral drugs
for pregnant and
non-pregnant staff)
for needle stick
injury should be
administered within
desired time frame.
67
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.
68
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.
69
Standard
EG.1. The responsibilities of those responsible for nursing management are

defined.

a. Those responsible for nursing For definition of This should be part
management lay down the vision refer to of nursing manual,
nursing department vision. glossary. refer NCP 1.
Only a display on its
website would not
be appropriate. It is
preferable that the
same be translated
and displayed in the
local language also.
b. Those responsible for nursing For definition of This should be part

management lay down the mission refer to of nursing manual,
nursing department mission. glossary. refer NCP 1.
website would not
preferable that the
same be translated
c. Those responsible for nursing For definition of This should be part
70
management lay down the values refer to of nursing manual,
nursing department values. glossary. refer NCP 1.
website would not
preferable that the
same be translated
d. Those responsible for nursing The nursing This should be part
management establish the management shall of nursing manual,
nursing department organogram. have a well-defined refer NCP 1.
organization
structure / chart and
this shall be clearly
document the
hierarchy, line of
control, along with
the function at the
various levels.
Standard
EG.2. The Head of the Nursing service ensures that suitable mechanisms exist to
govern the nursing Service.

a. There is an established head of The head of the
the nursing services. nursing services is
71
selected based
upon identified
criteria like
qualifications,
experience and
training received.
b. The scope of Nursing services is Self-explanatory. Self-explanatory.
defined in the nursing manual.
c. The Nursing administrative policy Self-explanatory. Self-explanatory.

and procedure is defined in the
manual and implemented.
d. The department manual shall Self-explanatory. Self-explanatory.

govern the nursing functions and
activities within the department.
e. Nursing administrative policy and Self-explanatory. Self-explanatory.

procedure is defined and
implemented.
f. Structured program exists for Self-explanatory. Self-explanatory.

enhancing clinical competency
and leadership skills of nursing
professionals.
g. The Nursing leaders are involved Self-explanatory. Self-explanatory.

in quality improvement projects
and program.
72
Standard
EG.3. Nursing professionals are involved and participate in decision making related
to organization and nursing services.

a. A Nursing Management Self-explanatory. Self-explanatory.
committee is established and it The periodicity of
meets periodically to oversee the meeting needs
Nursing related issues. to be specifically
defined by the HCO
and minutes of the
meeting are
recorded along with
the action taken
reports.
b. Nursing professionals have Self-explanatory.
membership in various Nursing
committees as appropriate. professionals shall
have representation
in Infection Control,
Grievance, Safety,
OT, Death Review
Committee, etc.
c. Nursing professionals providing Self-explanatory. Self-explanatory.
direct care are involved in action
plan development and evaluation
is based on evidence based data.
d. The organization has a This is reviewed Self-explanatory.
mechanism to seek feedback and improvement
from nursing professionals and opportunities are
73
other staff regarding the quality of identified and
nursing care and to for evaluating implemented
nursing satisfaction. accordingly.
Standard
EG.4. The Management empowers nursing staff.

a. There is a policy on nursing Self-explanatory. Self-explanatory.
empowerment to ensure timely
nursing care of patients.
b. Management empowers nursing Self-explanatory. Self-explanatory.
staff by involving them in decision
making.
c. Management empowers nursing Self-explanatory. Self-explanatory.
staff by appraisal and Job
incentives, encouraging
innovation.
d. Management empowers nursing Self-explanatory. Self-explanatory.

staff by supporting education.
e. Management empowers nursing Self-explanatory. Self-explanatory.

staff by promoting interpersonal
relationships.
Standard
EG.5. The organization has an established process for proactive risk assessment
74
and error management.

a. The Nursing service has clearly Self-explanatory. Self-explanatory.
defined error prevention, error
reporting and error addressing
mechanisms and the same are
documented.
b. The Nursing professionals are Self-explanatory. Self-explanatory.
provided with adequate resources
including materials and equipment
for providing safe and efficient
nursing services.
c. The nursing structure and Self-explanatory. Self-explanatory.
processes support a culture of
patient safety.
d. The Nursing professionals are Self-explanatory. Self-explanatory.

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 Self-explanatory. Self-explanatory.

and safety of the nursing
professionals are maintained such
that ability to practice is not
compromised.
f. There is an escalation process for Self-explanatory. Self-explanatory.
nursing professionals when
75
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 The organization Self-explanatory.
available resources required for shall ensure that the
the infection control practices. resources required
by the personnel
should be available
in a sustained
manner. This
includes both men
and materials.
b. The organization conducts There must be a
induction training for all staff. 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
76
infection control
programme.
c. The organization conducts Self-explanatory. Self-explanatory.
appropriate “in-service” training
sessions for all staff at least once
in a year.
77
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.
78
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.
79
Standard
NQI.1. There is a structured quality improvement and continuous monitoring

program for nursing service.

a. The quality improvement There is need for a At minimum, a
programme is developed, formal controlled „nursing manual‟
implemented and maintained by a documentation. shall be established.
committee with a representative This will be aligned This may refer to
from nursing personnel. with the SOPs where
organizations required.
quality improvement
program.
b. There is a designated individual Self-explanatory. This individual shall
for coordinating and implementing necessarily be a
the nursing quality-improvement senior and
programme. experienced nursing
professional
preferably with
exposure to NABH
and Quality
standards.
c. The quality improvement Self-explanatory. It should be
programme shall be reviewed at reviewed and
periodic intervals. updated atleast
once every year.
80
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 The factors Self-explanatory.
and the incident of patient falls is responsible for
documented by the appropriate patient fall can be
nursing professionals. classified as under:
1. Nursing related
2. Patient related-
unbalanced or
unsteady gait,
incorrect use of
equipment
3. Falls requiring
Medical
intervention
b. The hospital acquired decubitus / Self-explanatory. Self-explanatory.

pressure ulcers in various
departments are monitored and
recorded as per laid down
protocols by the HCO.
c. The medication errors during Self-explanatory. Self-explanatory.
provisioning of care are monitored
and recorded on occurrence by
the concerned nursing staff in
forms as laid down by the HCO.
81
d. Monitoring of accidental delining Self-explanatory. Self-explanatory
(if applicable).
e. All extravasations are recorded Self-explanatory. Self-explanatory.
and monitored as per the laid
down protocols.
f. All needle stick injuries are Self-explanatory. Self-explanatory.
documented and monitored as
per the policy laid down by the
HCO that should be in
consonance with the national and
International guidelines.
g. All restraint related incidents Self-explanatory. Self-explanatory.
including strangulation are
monitored and documented.
h. The hand hygiene compliance is Self-explanatory. Self-explanatory.
monitored and recorded by the The monitoring
nursing professionals responsible should be as per the
for the same. criteria identified by
the WHO guidelines
on Hand Hygiene.
i. The compliance with pain Self-explanatory. Self-explanatory.
assessment and management is
monitored by the senior nursing
professional while undertaking
their professional rounds and the
same is documented.
j. The satisfaction of patients with Self-explanatory. Self-explanatory.
the nursing care is monitored by
the senior nursing professionals
and the same is documented.
82
Standard
NQI.3. The nursing quality improvement programme is supported by the

management.

a. The management makes This shall include
available adequate resources the men, material,
required for quality improvement machine, money
programme. and method. These
should be in steady
supply so as to
ensure that the
programme
functions smoothly.
b. The management supports and Self-explanatory. For example, Root
implements use of appropriate Cause Analysis,
quality improvement, statistical FMEA, Project
and management tools in its Evaluation and
quality improvement programme. Review Technique
(PERT), Critical
Path Method
(CPM), Control
Charts, etc.
c. The senior nursing professionals Self-explanatory. Self-explanatory.
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.
83
d. The attrition rate and frequency of Self-explanatory. Self-explanatory.
attrition of the nursing
professionals is monitored and
documented by the head of the
nursing in consultation with the
human resource department of
the HCO.
Standard
NQI.4. There is an established system for nursing audit.

a. Nursing staff participates in The organization shall These could be
the audit. identify such personnel. members of the
It shall necessarily core
include senior and junior committee/nursing
nursing professionals quality assurance
and could be a mix of committee, etc.
clinicians and
administrators.
b. The parameters to be audited As these audits are The audit shall
are defined by the retrospective/concurrent encompass all
organization. in nature, it is imperative aspects of care
that this be done using including clinical
predefined parameters and nursing.
so that there is no bias.
The parameters could be
disease based, nursing
protocol based, nursing
84
documentation based,
cost based, community
based or based on
morbidity (length of
stay).
It shall lay down the
objectives, the
parameters that are
going to be captured,
develop a checklist
where required,
sampling and data
collection guidelines and
preparation of report.
c. Patient and staff anonymity is This means that the This is at the stage
maintained. names of the patients of report
and the hospital staff preparation and
who may figure in the dissemination. The
audit documents must staff participating in
not be disclosed or any the audit shall
reference be made to maintain patient
them in public and staff anonymity
discussions/conferences. and not reveal
names.
d. All audits are recorded and Self-explanatory. The organization
reviewed. could use a
checklist with the
predefined
parameters and the
audit findings could
be recorded on this
85
sheet.
e. Implementation is recorded All remedial measures This should
and reviewed. as ascertained should be preferably be done
documented and based on root-
implemented and cause analysis.
improvements thereof
recorded to complete the
audit cycle.
Standard
NQI.5. Incidents, complaints and feedback from nursing professionals are collected
and analysed to ensure continual quality improvement.

a. The organization has an incident The incident While capturing the
reporting system. reporting system organization shall
includes: capture all incidents
i. identification without going into
ii. reporting the severity or
iii. review whether harm was
iv. action on caused.
incidents.
b. The organization has a process to Self-explanatory. This shall be

collect feedback and receive communicated to
complaints. the patients using
displays or
brochures.
c. The organization has established The quality This could
86
processes for analysis of improvement preferably be done
incidents, feedbacks and committee (refer to by identifying the
complaints. CQI 1a) shall be root cause.
responsible for this Where possible, it is
activity. preferable that
patients be included
in analysing the
feedback and
complaint.
d. Corrective and preventive actions The objective of this All such action shall
are taken based on the findings of is to continually be documented.
such analysis. improve the quality
of patient-care
services.
e. Feedback about care and service At a minimum, This could be done

is communicated to staff. patient satisfaction using internal
levels shall be communication.
communicated on a It is equally
monthly basis. important that
positive feedback
about care and
service is
communicated to
staff.
87
GLOSSARY
The commonly-used terminologies in the NABH standards are briefly described and
explained herein to remove any ambiguity regarding their comprehension. The
definitions narrated have been taken from various authentic sources as stated,
wherever possible. Notwithstanding the accuracy of the explanations given, in the event
of any discrepancy with a legal requirement enshrined in the law of the land, the
provisions of the latter shall apply.
Certification The evaluation process for assessing the compliance of an

assessment organization with the applicable standards for determining its
accreditation status.
Advance life Emergency medical care for sustaining life, including

support defibrillation, airway management, and drugs and medications.
Adverse drug Adverse event: Any untoward medical occurrence that may
event present during treatment with a pharmaceutical product but
which does not necessarily have a causal relationship with this
treatment.
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
88
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
89
the outside world. The nursing professionals wear gowns,
masks, and gloves, and they observe strict rules that labeling the
risk of passing on infectious agents.
Basic life Basic life support (BLS) is the level of medical care which is used
support for patients with life-threatening illnesses or injuries until the
patient can be given full medical care.
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 Clinical practice guidelines are systematically developed

guidelines 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
90
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.
91
Disciplinary Sequence of activities to be carried out when staff does not
proceedings conform to the laid-down norms, rules and regulations of the
healthcare organization.
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 Evidence-based medicine is the conscientious, explicit, and

medicine 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-
92
term. Goals are ends that guide actions. (MBNQA)
Grievance- Sequence of activities carried out to address the grievances of

handling patients, visitors, relatives and staff.
procedures
Guidance The act or process of guiding someone or something.
Hazardous Substances dangerous to human and other living organisms.

materials 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- Healthcare-associated infections (HAIs) are infections caused by

associated a wide variety of common and unusual bacteria, fungi, and
infection viruses during the course of receiving medical care. (CDC)
This was earlier referred to as Nosocomial/hospital-acquired/

hospital-associated infection(s).
Healthcare Generic term is used to describe the various types of

organization organization that provide healthcare services. This includes
ambulatory care centres, hospitals, laboratories, etc.
High- A high-dependency unit (HDU) is an area for patients who

dependency unit 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
93
education/ for enhancing the skills of staff members or for teaching them
training 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
94
characteristics required for competent performance of the
job. A job description should describe and focus on the job
itself and not on any specific individual who might fill the job.
Job specification 1. The qualifications/physical requirements, experience and
skills required to perform a particular job/task.
2. A statement of the minimum acceptable qualifications that
an incumbent must possess to perform a given job
successfully.
Laws Legal document setting forth the rules of governing a particular
kind of activity, e.g. organ transplantation act, which governs the
rules for undertaking organ transplantation.
Medication error 1. A medication error is any preventable event that may cause
or lead to inappropriate medication use or harm to a patient.
(FDA)
2. A medication error is any preventable event that may cause
or lead to inappropriate medication use or patient harm while
the medication is in the control of the healthcare professional,
patient, or consumer. Such events may be related to
professional practice, healthcare products, procedures, and
systems, including prescribing, order communication, product
labeling, packaging, and nomenclature, compounding,
dispensing, distribution, administration, education,
monitoring, and use.(NCC MERP)
Mission An organization‟s purpose. (ASQ)
This refers to the overall function of an organization. The mission
answers the question, “what is this organization attempting to
accomplish?” The mission might define patients, stakeholders, or
markets served, distinctive or core competencies, or
technologies used. (MBNQA)
Monitoring The performance and analysis of routine measurements aimed
95
at identifying and detecting changes in the health status or the
environment, e.g. monitoring of growth and nutritional status, air
quality in operation theatre. It requires careful planning and use
of standardised procedures and methods of data collection.
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
96
care, in terms of their use of resources and the outcomes for
patients/clients, and introduces appropriate change in response
to that analysis (NHS ME, 1991 Framework for Audit for Nursing
Services).
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 A plan that identifies patient care needs, lists the strategy to
Plan 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 It is that component of standard which can be measured

element objectively on a rating scale. The acceptable compliance with
the measureable elements will determine the overall compliance
with the standard.
Occupational The hazards to which an individual is exposed during the course

health hazard 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
97
setting needs, e.g. ICU, speciality ward, private ward and general ward.
Patient record/ A document which contains the chronological sequence of

medical record/ events that a patient undergoes during his stay in the healthcare
clinical record organization. It includes demographic data of the patient,
assessment findings, diagnosis, consultations, procedures
undergone, progress notes and discharge summary. (Death
certificate, where required).
Performance It is the process of evaluating the performance of employees

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

evaluation and given project, especially the time needed to complete each task,
Review and to identify the minimum time needed to complete the total
98
Technique project.
(PERT)
PERT breaks down the project into events and activities, and
lays down their proper sequence, relationships, and duration in
the form of a network. Lines connecting the events are called
paths, and the longest path resulting from connecting all events
is called the critical path. The length (duration) of the critical path
is the duration of the project, and any delay occurring along it
delays the whole project. PERT is a scheduling tool, and does
not help in finding the best or the shortest way to complete a
project.
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
99
assurance that quality requirements will be fulfilled (Para 3.2.11 of ISO
9000:2000).
Quality Ongoing response to quality assessment data about a service in

improvement 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 Clinical and administrative activities to identify, evaluate and

management 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:
100
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 Root Cause Analysis (RCA) is a structured process that

Analysis (RCA) 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 Range of clinical and supportive activities that are provided by a

services healthcare organization.
Security Protection from loss, destruction, tampering, and unauthorised

access or use.
Senior Nursing The act or function of rendering advice or showing the correct
professional path on educational or vocational matters.
Staff All personnel working in the organization including employees,

“fee-for-service” medical professionals, part-time workers,
101
contractual personnel and volunteers.
Standard 1. A method of infection control in which all human blood and

precautions 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.
102
Transfusion A transfusion reaction is a problem that occurs after a patient
reaction receives a transfusion of blood.
Unstable patient A patient whose vital parameters need external assistance for
their maintenance.
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 Catheters, tubes, or device inserted into the vascular system,
Device including veins, arteries, and bone marrow.
Vulnerable Those patients who are prone to injury and disease by virtue of
patient their age, sex, physical, mental and immunological status, e.g.
infants, elderly, physically- and mentally-challenged, those on
immunosuppressive and/or chemotherapeutic agents.
103
104

National Accreditation Board For Hospitals and Healthcare Providers

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

National Accreditation Board For Hospitals and Healthcare Providers

Enviado por

Direitos autorais:

Formatos disponíveis

STANDARDS FOR NURSING EXCELLENCE

NATIONAL ACCREDITATION BOARD FOR

Chapter No Particulars Page No.

NURSING RESOURCE MANAGEMENT

Intent of the chapter:

There shall be an established procedure for addressing grievances.

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

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

The contents of the organizational level

b. A documented training and A training manual The training shall be

NRM.4. There is a process for credentialing and privileging of nursing professionals,

Sr.No Objective Elements Interpretation Remark(s)

can be under the mechanism to

proctorship till ensure that nursing

Sr.No Objective Elements Interpretation Remark(s)

b. The nursing professionals Self-explanatory. This could be

c. Performance is evaluated Self-explanatory. Key result areas are

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

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

NRM.9. The organization has a documented and established grievance handling

Sr.No Objective Elements Interpretation Remark(s)

NURSING CARE OF PATIENT

Intent of the chapter:

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

Empowered Nursing professionals embrace the concepts of managing patient and

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

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

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

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

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Intent of the chapter:

Designated nursing personnel shall be consulted during policy formulation pertaining to

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

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

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

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

Sr.No Objective Elements Interpretation Remark(s)

EDUCATION, COMMUNICATION AND GUIDANCE

Intent of the chapter: