HOSPITAL NURSING SERVICE ADMINISTRATION MANUAL a, DEPARTMENT OF HEALTH =| me) ):) Health Facility Development Bureau (HFDB)

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HOSPITAL NURSING SERVICE ADMINISTRATION MANUAL Published by the Department of Health (DOH) Health Facility Development Bureau (HFDB) Copyright @ 2019 All right reserved. No part of this book may be reproduced or used in any form or by any means, electronic or mechanical, including photocopying, recording, scanning or by any information storage and retrieval system without permission in writing from the publisher.

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tii Republic of the Philippines Department of Health OFFICE OF THE SECRE AUTHORIZATION December 16, 2019 In accordance with the authority vested on the Secretary of Health, | hereby declare the policies, regulations, and instructions in this Manual for Nurses shall govern the organization, management, and activities of the Nursing Service in government hospitals until modified by order of the Department of Health or by law. FRAXCISCO T. UE TH, MD, MSe Secretary of Health Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila © Trunk Line 651-7800 loc 1113, 1108, 1135 Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: htip:/www.dob.gov.pl: e-mail: fiduque@doh.gov.ph

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iv Republic of the Philippines Department of Health OFFICE OF THE SECRETARY ae MESSAGE \ LN : Moving towards the realization of its vision of hailing Filipinos among Southeast Asia’s healthiest people in 2022 and in Asia by 2040, the Department of Health (DOH) urges the health sector towards development of a Productive, Resilient Equitable, and People-centered health sector, as outlined in the Strategy Map of the DOH's FOURmula One Plus (F1 Plus) for Health. Aiming for better health outcomes, more responsive health system, and more equitable healthcare financing, especially now that the mandate for the implementation of the Universal Health Care Act has been geared at full capacity, measures to ensure high-quality and affordable health products, devices, facilities and services are essential. With these in mind, | commend the Health Facility Development Bureau (HFDB), for their initiative and commitment to harmonizing and streamlining standards and processes in health facility operations through its undertaking to update the Manual of Standards for Hospital Nursing Service Administration. Emulating the Department's core values of integrity, excellence and compassion, indeed, the Nursing Service is a fundamental aspect of hospital operations, wherein the nurses act as agents and ambassadors for the health sector in its entirety. Hence, we trust that the updated standards defined in this manual shall serve as a relevant basis to benchmark enrichment of equitable access to quality health facilities thai offer health services compliant to the standards of care. Keeping in mind performance accountability across all pillars of F1 Plus, particularly service delivery, may these manual, along with the HFDB’s engagement to its partners in the delivery of quality health care for all, ease the better execution of policies and programs in the DOH. Aligned with the mandate of UHC towards a people-centered approach for delivery of health services that is focused on people's needs and well-being, while recognizing the Filipino people’s varying cultures, belief, and values, we are confident that this manual shall be instrumental in fulfilling the DOH’s aspiration of delivering “Kalusugang Pangkalahatan’ that this nation needs. FRANZISCO T.DI E, lll, MD, MSc Secretary of Health Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila @ Trunk Line 631-7800 loc 1113, 1108, 1135 Direct Line: 711-9502; 711-9503 Fax: 743-1829 © URL: http: www. dob.cov.ph; e-mail: fiduque@doh.gov.ph

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Repuhke of the Paciss Deperiment. ef Heelih OFFICE OF THE SECRETARY MESSAGE ‘Aith the implementacon of ine Universal Health Gare (UHC! Law, Filpinos will have delter health outcomes across popwiatice groups a more responsive healt system tha maxes people feel ressected. valued and amrowered, and ficancial risk cvotecdion, Health facrites are whers patietts expect lo exnerience the best nealh care and treatrrent Healt faciliies must ther be venues of clnca quality, oporallsaal eficioney anc seopic- cenlerer protesses. The updaed Hospital Nursing Service Administration Manual aims to better sespenc to pation! needs Sy i‘lecting the tslest develoomerts in evidence-based nursing care end maragament praciicus. We save accounted for the diverse spectrum cf health care settings and resources, while keesing trie to the fundamental princisie cf effmert anc effective velivery of a com: ruum of quality sare. This marual is organized ia two saris. Parl 1s on Admisstmilion of Nursirg Services, which discusses the ends and directiors for the DO4 and the rursng service, as well as nisns to Improve slanning. organization, staffing, diroclng and controlling of the hace. Part lis 4 Manegenent of Heallhcare Delwery, which dscusses fie bends sing processes, atodablies cf can B iy eng Ie implement the standards ir his Manusia Thank you vary much and Ses: wishes to ail! a rat LAD LILIBETH € bavin, Mia, Mpuchirni, CESO Hi Undersecretary of Health Health Facilities and Infristrucnars Developinent eam Buadir = 2, Sar seanec Corgan, tw Avenir, sta Lew, WCE Marts @ Teak tie £5. FRED bead 105s, PB 1125 SMES Ue. FAL-OG02: TLE-GSIS faa: TES-1B79 © lt > bets SAew.ris® eee ph eral Hd eo 2 Oo

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vi Republic of the Philippines Deparimeat af Healeh ADMINISTRATION AND FINANCIAL MANAGEMENT TEAM MESSAGE The government through tae Department of Health is committed invest maki Filipinas the healthies! in Southegst and in Asia by 2040. Yo realize t} ion, iL is imparient that we harness 4 health system that is not only superior in lenms of prov ‘ding topactch facilities, deviecs and services but is also responsive and scnsitive to clients’ plizhis aad needs, With the Usiversal Heath Care: finally tak that apart from inaking reasonably prices i available to the public, im-und oui pationts, <i itis now only a matter of time for us io see lui services und curmoditics accessible and ull facilities also give equal premium bo nurturing and caring for ins {to this note, | congratulude the Healih Facility Development Mureau for his another milestone. We are confident tha: this updated edition of Hospital Nursing Service Achninistration Manual will help tnise the qu 3 i provide lo thvir patients whether they sre working in private or state-run hospitals and medical centers. a * ROGER P.TONG-AN, MPA, MAN, RN Undersecretary Administration and Financial Manapement Team ‘Crux, 1003 bianlla « Tron }4np 651-7990 lool 243, E241. 1232, © 2" lore Isnibding 2 Sou Varava Paypal, i 5 : acovopls © mull: usecthugenabrayeu ERI cho

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FOREWORD The Health Faciiity Development Bureau (HF DB) of the Department of Health is charged es that are efficient ana 72 to the needs of the Filipiaes. Tovearcs this enc, the Berecu i rasicd to develop policies, programs and standards, as well as provide technical assistance and advisory services in the development, planning, operations and maintenance of health facilities. with leading in die continuous developarene of quality health faci ! Health Car2, FOURmuis Guz Plas for «of the Philippine Health Fecilitv s on People-Centered Health Care Fo: the DOH’s fagship program to do5st Uni Yealth, the HFDB is commitied to the cevelop Development Plan, policies and recognition mechanis Services, Patient Savery and Infection Prevemion and Control, and manuals on health racility operations for quality services and integration. All these strategic functions serve to implement the DOH’s mandates in the implementation of Republic Aet No. 11223, or the Universal Health Care Act. The targeted health facility manuals include this updated edition of the Hospital Nursing Service Administration Manual. The HFDB is extremely grateful for the generosity of the Technical Working Group meinders, the invited resource persons, aid other stakeholders, whe cedicated their tae, expertise and eo te enstie that iis letest edition of the manual shall be of sufficient content and convenient form to address the hossitals’ needs fer continuous quality improvement especially among nursing service administrators and staff. y e people's primary interface with the health system. It is at this juncture, where the Filipinos’ expectations and the genuine changes brought by Universal Health Care intersect. The Bureau hopes that this and our other initiatives, as well as your i ; will sty nthe DOH's ¢ in! risk ice delivery, and better health outcomes for all. coals of finen enthys-astic ¢ protection, a more responsive health serv ae os PUL LINE BUA AC PO MA. THERESA/G VERA. MD, MSc, MH4, CESO Ul Director IV Heaith Facility Deveiopmient Bureau vii

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PREFACE It is indeed with profound appreciation and gratitude that I acknowledge the members of the Technical Working Group (TWG) and Technical Contributors, who collectively shared their knowledge and competence in the preparation of this 4 Edition of the Hospital Nursing Service Administration Manual. Today’s health care organizations face tremendous challenges. In any given day of running organizations, these challenges become pressures that impact the decisions that managers make and execute. This Manual intends to explain how organizational goals can be achieved, and it shall define the scope of activities to be conducted to accomplish such goals. This Manual was designed to ensure accessibility and flexibility of more efficient operations of nursing activities with tools provided to meet needs in the development, promotion and enhancement of quality nursing care. The Department of Health (DOH), in consultation with stakeholders, reviewed and updated the Manual mindful to make introduction and application of new knowledge more practical. The reviews entailed all the chapters published from the third edition, and new chapters were added to address the clinical practices of nurses in DOH Hospitals. The text expanded to ensure more practical advice speaks to the needs of administrators to respond more effectively to problems and issues in aid of management. For this 4"" Edition, the Manual’s chapters are reorganized and regrouped according to similar aspects of management and nursing care. Part I covers the Administration of Nursing Services in which information and discussion on major functions of Nursing Administrators are aimed to inspire desirable attitudes and predisposition to perform duties and responsibilities such as setting appropriate courses of action according to needs that arise. Part Il addresses the Management in the Delivery of Nursing Care Services in which competencies that are essential for the development of the nursing staff are identified, the competencies that enable performance of roles and responsibilities in promotive, preventive, curative and rehabilitative aspects towards attainment of quality patient care. This Manual is capped with appendices of step-by-step processes and procedures, as well as a list of references or sources from which many updated information herein were drawn. On behalf of TWG and the Technical Contributors, we at the Health Facility Development Bureau (HFDB) of the DOH wish that your continual use of this Manual will significantly contribute to the optimal development of Nursing Service Administration, truly responsive and effective in the management of nursing care services in the hospitals. Ma Ln [are ZENAIDAIL VILLALUNA, RN, MAN, Ed.D. Development Management Officer IV (DMO IV) Nursing Adviser Chairperson, Committee on Revision DOH Hospital Nursing Service Administration Manual

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ix ACKNOWLEDGEMENT The Department of Health, Health Facility Development Bureau (HFDB), would like to express deepest gratitude with the participation of several DOH Hospitals and previous committee in the revision of 2008 Hospital Nursing Service Administration Manual, for their invaluable contribution, support and encouragement made this 2019 Revised Manual a reality. Dr. Lilibeth C. David, Undersecretary of Health, Health Facilities and Infrastructure Development Team; Dr. Gerardo V. Bayugo, Undersecretary of Health, Field Implementation and Coordination Team; Dr. Roger P. Tong-an, Undersecretary of Health, Administration and Financial Management; Dr. Criselda G. Abesamis, former Director IV, DOH, Health Facility Development Bureau (HFDB) Dr. Ma. Theresa G. Vera Director IV, DOH, Health Facility Development Bureau To all DOH Medical Center Chiefs, Chief of Hospitals and staff for allowing their Chief Nurses to attend series of Consultative Conferences in the revision of the said Manual. Our deepest thanks and appreciation to the following Medical Center Chiefs for their invaluable support and for offering their resources during committee meetings: Dr. Alfonso G. Nufiez, East Avenue Medical Center; Dr. Epifania Simbul, National Children’s Hospital; Dr. Jose Brittanio S. Pujalte, Philippine Orthopedic Center; Dr. Evelyn Victoria E. Reside, Quirino Memorial Medical Center; Dr. Maria Isabelita M. Estrella, Tondo Medical Center; Dr. Jeffrey Antony T. Canceran, Batanes General Hospital; Dr. Ramoncito C. Magnaye, Batangas Medical Center; Dr. Alfonso Victorino H. Famaran, Dr. Jose N. Rodriguez Memorial Hospital; Dr. Agustin D. Agos, Talisay District Hospital; Dr. Gerardo M. Aquino Jr., Vicente Sotto Memorial Medical Center; Dr. Bryan O. Dalid, Davao Regional Medical Center; Dr. Leopoldo J. Vega, Southern Philippines Medical Center; Likewise, we would wish to express our thanks to the Technical Working Group (TWG), Contributors and Nursing Consultants, who patiently reviewed and took necessary changes to make this new edition relevant to the needs of today’s Nursing Service Administration:

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Technical Working Group (TWG) on the Committee on the Revision of the Hospital Nursing Service Administration composed of: Chairperson, Dr. Zenaida I. Villaluna, HFDB, DMO IV, (Nursing Adviser); Members, Ms. Daisy L. Llarenas, Chief Nurse, National Children’s Hospital; Dr. Evelyn T. Monsanto, former Chief Nurse, Zamboanga City Medical Center; Dr. Amor B. Calayan, Chief Nurse, Batangas Medical Center; Ms. Flordeliza R. Bobiles, Chief Nurse, Ilocos Training and Regional Medical Center; Dr. Vilma L. Comoda, Chief Nurse, Southern Philippines Medical Center; Dr. Laura B. Libunao, Chief Nurse, Philippine Orthopedic Center; Mr. Joselito M. Datud, Chief Nurse, Baguio General Hospital and Medical Center; Ms. Marybeth G. Marcial, Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital Contributors, Dr. Nora B. Mangahas, Chief Nurse, Amang Rodriguez Memorial Medical Center; Dr. Flor P. Burgos, Chief Nurse, East Avenue Medical Center; Ms. Ma. Mercy C. Coral. Chief Nurse, Davao Regional Medical Center; Ms. Pinky Miriam D. Canlas, Chief Nurse, Dr. Paulino J. Garcia Memorial Research and Medical Center; Ms. Edna E. Solis, Chief Nurse, Dr. Jose Fabella Memorial Hospital; Ms. Rhodora D. Quilantip, Chief Nurse, Tondo Medical Center; Ms. Miriam I. Ramones, Chief Nurse, Mariano Marcos Memorial Hospital and Medical Center; Dr. Luz P. Padua, Chief Nurse, Quirino Memorial Medical Center; Ms. Marieta I. Gonzales, Chief Nurse, Region 1 Medical Center; Ms. Alicia N. Salamanca, Chief Nurse, Jose R. Reyes Memorial Medical Center; Ms. Sheila M. Mira, Assistant Chief Nurse, Northern Mindanao Medical Center; Ms. Elvira N. Baura, Deputy Executive Director III, Lung Center of the Philippines; Ms. Elsie Sarabia, former Chief Nurse, Jose R. Reyes Memorial Medical Center; Nursing Consultants, Dr. Lucila O. Espinosa, former Chief Nurse, National Center for Mental Health; Dr. Marie Therese Pacabis, former Chief Nurse, Dr. Jose Fabella Memorial Hospital; Dr. Leonora Collantes, former Chief Nurse, St. Luke’s Medical Center;

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xi Dr. Elvira Urgel, Dean, Centro Escolar University School of Nursing; Dr. Erlinda C. Palaganas, Philippine Nurses Association; Ms. Charity Y. Perea, National League of Philippine Government Nurses Inc.; Dr. Glenda S. Arquiza, Chairperson, Professional Regulatory Board of Nursing; Dr. Gloria B. Arcos, Member, Professional Regulatory Board of Nursing; Ms. Balbina M. Borneo, President, Mother & Child Nurses Association of the Philippines; Dr. Annabelle Borromeo, former Chief Nurse, St. Luke’s Medical Center; Dr. Nancy M. Felipe, Philippine Women’s University Dr. Cristina Caalim, Philippine Society for Quality in Healthcare; Dr. Ma. Linda G. Buhat, President, Association of Nursing Service Administrators of the Philippines; Ms. Iloida M. Flores, Nurse V, Health Facilities and Services Regulatory Bureau; Mr. Manuel Castillo Jr. SR HRS, DOH-Civil Service Commission Secretariat, Ms. Sarah Sacdalan-Levy, HFDB, DMO II Also, our deepest gratitude to all Chief Nurses and Stakeholders representing DOH Hospitals from NCR, Luzon, Visayas and Mindanao for participating in the review of the manual: Ms. Elvira N. Baura, Deputy Executive Director III], Lung Center of the Philippines; Dr. Nerissa M. Gerial, Deputy Executive Director, National Kidney and Transplant Institute; Dr. Amelinda S. Magno, Deputy Executive Director, Philippine Children’s Medical Center; Ms. Marietta A. Velasco, Acting Deputy Executive Director, Philippine Heart Center; Dr. Nora B. Mangahas, Chief Nurse, Amang Rodriguez Memorial Medical Center; Ms. Edna E. Solis, Chief Nurse, Dr. Jose Fabella Memorial Hospital; Dr. Flor P. Burgos, Chief Nurse, East Avenue Medical Center; Ms. Alicia N. Salamanca, Chief Nurse, Jose R. Reyes Memorial Medical Center; Mr. Publio B. Plotefia III, Chief Nurse, National Center for Mental Health; Ms. Daisy L. Llarenas, Chief Nurse, National Children’s Medical Center; Dr. Laura B. Libunao, Chief Nurse, Philippine Orthopedic Center; Dr. Luz P. Padua, Chief Nurse, Quirino Memorial Medical Center; Ms. Loida A. Oliquino, Chief Nurse, Research Institute for Tropical Medicine; Ms. Louise Marie Flores, Chief Nurse, Rizal Medical Center; Ms. Ofelia C. Ibarrientos, Nurse VI, Rizal Medical Center; Mr. Ferdinand A. Lazaro, Chief Nurse, San Lazaro Hospital; Ms. Rhodora D. Quilantip, Chief Nurse, Tondo Medical Center;

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xii Ms. Flordeliza R. Bobiles, Chief Nurse, Ilocos Training Regional & Medical Center; Ms. Miriam I. Ramones, Chief Nurse, Mariano Marcos Memorial Hospital & Medical Center; Ms. Marieta I. Gonzales, Chief Nurse, Region 1 Medical Center; Mr. Joselito M. Datud, Chief Nurse, Baguio General Hospital & Medical Center; Ms. Norzalyn C. Baguec, Chief Nurse, Conner District Hospital; Ms. Wennie C. Lawat, Nurse Supervisor, Far North Luzon General Hospital & Training Center; Ms. Carmelita O. Lud-ayen, Chief Nurse, Luis Hora Memorial Regional Hospital; Ms. Agnes V. Delfin, Nurse Supervisor, Batanes General Hospital; Ms. Olivia S.B. Gonzales, Chief Nurse, Cagayan Valley Medical Center; Ms. Rosalinda C. Mendoza, Chief Nurse, Southern Isabela General Hospital; Ms. Nelia M. Vicente, Chief Nurse, Veterans Regional Hospital; Ms. Evelyn R. Rubia, Chief Nurse, Bataan General Hospital; Ms. Pinky Miriam D. Canlas, Chief Nurse, Paulino J. Garcia Memorial Research & Medical Center; Ms. Luz M. Chiong, Chief Nurse, Jose B. Lingad Memorial Regional Hospital; Dr. Amor B. Calayan, Chief Nurse, Batangas Medical Center; Ms. Leticia D. Romero, Chief Nurse, Mariveles Mental Hospital; Mr. Ericson L. Co So, Chief Nurse, Talavera Extension Hospital; Dr. Amor B. Calayan, Chief Nurse, Batangas Medical Center; Ms. Lynn A. Sotero, Chief Nurse, Culion Sanitarium and General Hospital; Ms. Maria Theresa P. Silva, Nurse V, Ospital ng Palawan; Ms. Amelia V. Enriquez, Chief Nurse, Bicol Medical Center; Ms. Cecilia E. Dela Pefia, Chief Nurse, Bicol Regional Training & Teaching Hospital; Ms. Shirley P. Orain, Chief Nurse, Bicol Sanitarium; Mr. Samuel C. Sumilang, Chief Nurse, Dr. Jose N. Rodriguez Memorial Hospital; Ms. Josephine L. Balubar, Chief Nurse, Las Pifias General Hospital & Satellite Trauma Center; Ms. Leonora B. Destacamento, San Lorenzo Women’s Hospital; Ms. Dona D. Salmos, Chief Nurse, Valenzuela Medical Center; Ms. Marybeth G. Marcial, OIC-Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital; Ms. Ma. Cecilia G. Montero, Chief Nurse, Don Jose Monfort Medical Center Extension Hospital; Ms. Violeta C. Calopez, Chief Nurse, Western Visayas Medical Center; Ms. Ma. Eloisa S. Penado, Chief Nurse, Western Visayas Sanitarium; Ms. Ma. Corazon O. Sarabosing, Chief Nurse, Don Emilio Del Valle Memorial Hospital; Ms. Leny B. Maramara, Chief Nurse, Eversely Child Sanitarium; Ms. Tita S. Araneta, Chief Nurse, Gov. Celestino Gallares Memorial Hospital;

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Moreov xiii Ms. Jonah Lydia G. Langga, Chief Nurse, St. Anthony Mother & Child Hospital; Mr. Harby O. Abellanosa, Chief Nurse, Talisay District Hospital; Ms. Sara V. Sanchez, Chief Nurse, Vicente Sotto Memorial Medical Center; Ms. Fe Cuaton, Chief Nurse, Eastern Visayas Regional Medical Center; Dr. Dolores Y. Casio, Nurse VI, Eastern Visayas Regional Medical Center; Ms. Luisa G. Villocino, Chief Nurse, Schistosomiasis Control & Research Hospital; Ms. Marilyne G. Ibarra, Chief Nurse, Basilan General Hospital; Ms. Adora Tambasen, Chief Nurse, Dr. Jose Rizal Memorial Hospital; Ms. Marylou O. Mercado, Chief Nurse, Labuan Public Hospital; Ms. Nona C. Galvez, Chief Nurse, Margosatubig Regional Hospital; Ms. Josephine C. Paragas, Chief Nurse, Mindanao Central Sanitarium; Ms. Juvelyn T. Tan, Chief Nurse, Sulu Sanitairum; Ms. Ellen V. Macias, Chief Nurse, Zamboanga City Medical Center; Ms. Marilyn D. Lucman, Chief Nurse, Amai Pakpak Medical Center; Ms. Gerlie S. Alima, Chief Nurse, Mayor Hilarion A. Ramiro Sr. Medical Teaching Hospital; Ms. Mary Ann S. Pacana, Chief Nurse, Northern Mindanao Medical Center; Ms. Ma. Mercy C. Coral, Chief Nurse, Davao Regional Medical Center; Dr. Vilma L. Comoda, Chief Nurse, Southern Philippines Medical Center; Ms. Elma Lorna P. Coloso, Chief Nurse, Cotabato Regional Medical Center; Ms. Maria Kristine G. Portaje, Nurse V, Cotabato Regional Medical Center; Ms. Bai Sittie Abrala L. Mamadra, Chief Nurse, Cotabato Sanitarium; Ms. Ella June C. Delos Reyes, Chief Nurse, Adela Serra Ty Medical Center; Ms. Mercy A. Yandra, Chief Nurse, Caraga Regional Hospital ver, we would like to extend our thanks to all HFDB Advisers and Staff who contributed to the text and procedures, write and highlight sections that may have been unclear: Ms. Dr. Ms. Ms. Ms. Ms. Ms. Ms. Ms. Mr. Mr. Mr. Mr. Madeliene Gabrielle M. Doromal, Medical Social Work Adviser; Anthony B. Cu, Medical Officer V; Faye Diana C. Chua, Pharmacy Adviser; Josephine L. Guiao, Dietary Adviser; Angelita O. Jimenez, Laboratory Adviser; Chrys Abigail Paita, Focal Person for Hospital Health Information Management; Karen Joy Gregorio, Focal Person for Hospital Finance Service; Clara Francesca Roa, IHOMP Coordinator; Joy Padrigano, DMO III; Infection Prevention Control Coordinator; Joy Jardinero, DMO II; Richard Albert Ramones, Medical Technologist II Roderick M. Napulan, DMO IV; Erickson Feliciano, DMO IV; Ms. Dianne Melody De Roxas, DMO IV; Mr. Mr. Mr. Glen Cruz, DMO III; Learsi Ray Afable, DMO III; Armando Sufie, DMO III;

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xiv Mr. Michael Macapallag, Administrative Officer IV; Ms. Laika S. Guerrero, Administrative Assistant V; Mr. Henry Ryan Dominic G. Cajandig, Administrative Assistant III; Ms. Lea A. Erlandez, Administrative Assistant VI; Ms. Camille Ann C. Ople, Senior Administrative Assistant II; Mr. James Bryan B. De Guzman, Research Fellow Ms. Rhod-Ann Lebrino, Administrative Assistant III; Mr. Ricky Ocampo, Maintenance

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xv HOSPITAL NURSING SERVICE ADMINISTRATION MANUAL TECHNICAL WORKING GROUP ZENATA I. VILLALUNA, RN, MAN, Ed.D. Chairperson Development Management Officer IV (DMO IV) Nursing Adviser Health Facility Development Bureau Members: DAISY L. LLARENAS, RN, MAN Chief Nurse, National Children’s Hospital EVELYN T. MONSANTO, RN, PhD Chief Nurse, Zamboanga City AMOR B. CA YAN, RN, PhD Chief Nurse, Batangas Medical Center FLORDELIZA R. BOBILES, RN, MAN Chief Nurse, Ilocos Training and Regional Medical Center w——~—e— VILMA L. COMODA, RN, PhD Chief Nurse, Southern Philippines Medical Center LAURA LIBUNAO, RN, PhD Chief Nurs, Philippine Orthopedic Center JOS*LIDO M. DATUD, RN, MSN Chief Nurse, Baguio General Hospital and Medical Center uarvouril seaxciAt, RN, MN OIC-Chief Nurse, Corazon Locsin Montelibano Memorial Regional Hospital

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HOSPITAL NURSING SERVICE ADMINISTRATIONMANUAL TECHNICAL CONTRIBUTORS Vor ri gains aes NORA IANGAHAS, RN, PhD. FLOR PL stv MAN, Ed.D. Chef Nuce Chef Nurse Ammons Rodigque? Memicici! MedicalCerre fre: Averic Med cal Center x Nheyaluy MA, MERCY C. CORAL RN, BAKA, MAN PINKY MIRIAM D. CANLAS, RN. MAN oral fAedical Contor » Paulinis b. Gaiis memoral é bx ea y byeodcde

• SOUS, RN, MAN RHODORA dounaéie, RN, MAN forse 5 +. duse Fubsll ay Ho: fiANCA RN, MAN Jose R. Rayos Mamora Medco Center SHEILA MIRA, RN, MAN evidh WYEKIRZ, ah, MAN Assiscar’ Oriet Nune Deputy Executive Sector li Horthem Mindarao médical Center Lung Cantor of thr: Paiipoines G Agthrdhie-" ELSIEGARABIA, RN, MAN Formet Chief huse Jose Reyes Momo‘ Medics Certe

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FMEA GSIS 1 HAMA - xvii LIST OF ABBREVIATIONS Assistant Chief Nurse Association of Nursing Service Administrators of the Philippines Administrative Order American Organization of Nurse Executives Critical Incident Reporting System Chief of Medical Professional Staff Chief Nurse Capital Outlay Chief of Hospital Continuous Quality Improvement Civil Service Commission Central Supply Room Data Action Response Development Management Officer Department of Health Department Personnel Order Enterprise Risk Management Economic Order Quantity Failure Mode and Effect Analysis Government Service Insurance System Home Against Medical Advise

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Hospital as Center of Wellness Health Care Workers Health Education Promotion Officer Health Facility Enhancement Program Human Resource Development Human Resource Management Health Technology Assessment Institute of Medicine Infection Prevention Control Inspection, Percussion, Palpation and Auscultation Joint Commission on Accreditation of Health Care Organization Learning and Development Intervention Local Government Unit Local Investment Plan for Health Medical Center Chief Maintenance and Other Operating Expenses Magnetic Resonance Imaging Nursing Care Hours Neonatal Intensive Care Unit National League of Philippine Government Nurses Organizational Effectiveness Organizational Performance Philippine Development Plan Physical Examination

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PHICS PhilHealth PHC PHU PNA PNDF PPP PS PSI QIP QMS QM RA SDN TA TQM UHC UDDS xix Philippine Hospital Infection Control Society Philippine Health Insurance Primary Health Care Public Health Unit Philippine Nurses Association Philippine National Drug Formulary Primary Health Care, Promotion of Health, Prevention of Diseases Personnel Services Patient Safety Indicator Quality Improvement Plans Quality Management System Quality Management Republic Act Service Delivery Network Technical Assistant Total Quality Management Universal Health Care Unit Drug Dose System

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TABLE OF CONTENTS Authorization Message Foreword Preface Acknowledgement List of Abbreviation List of Tables List of Figures List of Appendices PART I] - THE ADMINISTRATION OF NURSING SERVICES 1 THE DEPARTMENT OF HEALTH Vision Mission Core Values Strategic Goals 2 THE NURSING SERVICE Vision Mission Philosophy Core Values Strategic Goal Philosophy and Objectives of the Nursing Service Conceptual Framework Nursing Service Standards, Policies and Procedures The Philippine Professional Nursing Practice Standards Development of Nursing Standards in the Philippines Nursing Service Policies The Nursing Service Policy Manual Nursing Procedures Advantages of Sound Personnel Practices in Nursing Service Administration 3 PLANNING THE NURSING SERVICE Importance of Planning Characteristics of a Good Plan Page iii iv Vii Vili ix XVII Xxvil xxviii XXX 25 25 26

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TABLE OF CONTENTS (continued) Types of Planning Kotter's 8-Step Change Model Steps in Strategic Planning Steps in Planning the Nursing Service Tools in Planning SWOT Analysis Pestel or Pestle Analysis STEEPLE Analysis Balanced Scorecard Budgeting for the Nursing Service Project Planning ORGANIZING THE NURSING SERVICE Purposes of Organizing Organizing Principles Nursing Service as an Organization The Organizational Structure of the Nursing Service Organizational Chart and its Implication Organizational Effectiveness Organizational Culture Teamwork Team Building Nursing Service Committees STAFFING IN THE NURSING SERVICE Principles of Staffing Factors Affecting Staffing Patient Care Classification System Staffing Methods Staffing Formula Shift Options Scheduling Assignment Job Description DIRECTING THE NURSING SERVICE Principles of Directing Characteristics of Directing Elements of Directing Supervision Problem Solving and Decision Making Delegation Communication, Teamwork and Coordination Motivation Page 26 27 29 33 34 35 39 40 4 43 47 49 49 50 51 51 53 59 60 61 62

re] 65 66 66 67 71 74 dS 76 78 79 81 82 83 83 83 88 89 93 104

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TABLE OF CONTENTS (continued) CONTROLLING THE NURSING SERVICE Controlling Guidelines for the Nursing Service Administrator Control Measures Utilized by the Nursing Service Administrators Performance Appraisal Performance Management System (PMS) Recording and Reporting Employee Discipline Employee’s Code of Conduct Disciplinary Conference Due Process Handling Complaints Conflict Management Change Management PART II —THE MANAGEMENT IN THE DELIVERY OF NURSING 10 CARE SERVICES NURSING PROCESS Introduction Purposes of the Process Benefits of the Nursing Process Steps of the Nursing Process Nursing Assessment Nursing Diagnosis Nursing Planning and Outcome Identification Nursing Implementation Nursing Evaluation MODALITIES OF CARE Introduction Functional Nursing Total Care or Case Nursing Primary Nursing Team Nursing QUALITY MANAGEMENT Introduction Definition of Terms Principles of Total Quality Management Strategies in Total Quality Management Quality Improvement Plans (QIP) Work as Systems and Processes The Role of Organizational Leadership Quality Improvement Program XXII Page 107 109 110 110 113 116 117 117 118 119 120 122 127 129 131 131 131 132 132 32 133 133 134 134 137 137 138 139 140 141 143 143 144 146 146 147 149 150 151

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11 12 TABLE OF CONTENTS (continued) Nursing Quality Improvement Continuous Quality Improvement (CQI) The PDCA or PDSA Cycle Roles of Nursing Leaders Methods of Nursing Audits Quality Circle Quality Assurance SAFETY IN HEALTH CARE Introduction Definition of Terms Key Elements of Patient Safety Ten (10) Reasons for Global Patient Safety Strategies that Promote Patient Safety Types of Errors Medication Errors The Nurse’s Responsibility for the Patient’s Safety Emergency Care Consent (Right to Informed Consent) Therapeutic Orders The Generics Act Law (RA 6675) Medication Rights Indicators and Parameters of Safety Nursing Actions to Improve Patient Safety Implementing Policies on Accidents Patients’ Safety Implementing Policies Occupational and Environmental Health Nursing Infection Prevention and Control (IPC) Standard Precautions Management of Patients with Suspected MRSA Infection or Colonization Needlestick Injury Safe Transfusion of Blood and Blood Component RISK MANAGEMENT Introduction Importance of Risk Management Strategies of Risk Management Clinical Risk Management Principles of Risk Management Essentials for Risk Management Program Risk Management Process Risk Identification Page 151 153 154 158 159 160 160 171 171 171 172 173 174 178 179 181 181 181 182 182 183 183 184 185 186 188 189 192 194 194 196 199 199 200 201 202 203 204 205 209

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13 14 15 TABLE OF CONTENTS (continued) Scope of the Risk Management Risk Potential Essentials of Risk Management Program Risk Management Committee Strengthening the Risk Management Program Tools and Practices Failure Mode and Effect Analysis (FMEA) NURSING INFORMATION MANAGEMENT SYSTEM Introduction Importance of Nursing Information Management Information System Hospital Information System Integrated Hospital Operations and Management Program (IHOMP) Integrated Hospital Operations and Management Information System (iHOMIS) Records Management Nursing Office Records Required Patients’ Data That Needs to be Documented Nursing Documentation Nursing Kardex Discharge Against Medical Advice (DAMA) ETHICO-LEGAL IN NURSING LEADERSHIP Introduction Ethical Concerns Confronting Nurses Ethical Principles Ethical Conflicts Technological Concepts and Ethical Practice Ethical Considerations in Patient Care Nurse’s Legal Responsibility for Patient Care Therapeutic Orders Causes of Malpractice for Nurse Managers and Nurses Disciplinary Action on Errors HUMAN RESOURCE MANAGEMENT Introduction Importance of Human Resource Management Human Resource Development Program PRIME-HRM Page 211 212 213 215 215 218 220 223 223 223 223 225 226 227. 229 230 234 238 243 244 245 245 245 246 248 249 249 250 253 254 256 257 257 251 261 268

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xxvi TABLE OF CONTENTS (continued) Page 16 MANAGEMENT OF SUPPLIES AND EQUIPMENT 271 Introduction 271 Materials, Supplies and Equipment Inventory System 272 Preventive Maintenance of Equipment 273 Guidelines in the Management of Supplies and Equipment 274 Inventory 274 Stock Control 277 17 HOSPITAL AS PEOPLE-CENTERED HEALTH CARE 281 Introduction 281 Potential Benefits of People-Centered and Integrated Health 282 Services Key Principles in People-Centered Care 284 People-Centered Health Services 284 Perspectives in Quality 285 REFERENCES 287

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Xxvil LIST OF TABLES Table Page 3.1 Differences between the Strategic Planning and Operational 28 Planning 5.1 Classification of Patient Care by Units, Nursing Care Hours/ 68 Patient/Day and Ratio of Registered Nurses to Non-Professional Staff Needed 52 Classification of Patients by Levels of Care, Nursing Care 69 Hours/Patient/Day and Ratio of Professionals to Non- professionals Needed 5.3 Classification of Patients by Levels of Care according to Type 70 of Hospital with Percentage of Patients at Various Levels of Care 5.4 Nursing Staffing Standards for Government Hospitals 71 5.5 Total Number of Working days, Non-Working days and 73 Working Hours of Nursing Personnel per Year 5.6 Personnel Staffing Schedule: Eight-Hour Shift 76 12.1 Likelihood Scale 207 122 Loss or damage impact scale 207 12.3 Risk Priority Scale 208

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Figure 1.1 1.2 2-1 22 3.1 3.2 333; 3.4 30 4.1 4.2 4.3 7.1 7.2 8.1 9.1 9.2, 93 9.4 10.1 10.2 10.3 10.4 12.1 12.2. 12.3 LIST OF FIGURES F1 Plus Strategy Map DOH Functional Management Team The Nursing Management System The Nursing Management Process Five-Step Process in Succession Planning Example # 1 of SWOT Analysis Example #2 of SWOT Analysis Example of Pestel or Pestle Analysis Framework of Balance Scorecard Organizational Chart Organizational Structure Showing the Relationships of the Nursing Service with the College of Nursing Functional Structure of the Nursing Service Showing Levels of Position Performance Management System Cycle Steps of Progressive Discipline The Nursing Process Functional Nursing Care Delivery Model Total Patient Care Nursing Delivery Primary Nursing Care Team Nursing Care Inputs, Processes and Outputs/Outcomes Quality Improvement in Practice Quality Improvement in Nursing Nursing Quality Indicators Risk Management Risk Management Process Risk Management Steps xxvill Page 10 15 16 28 37 39 40 42 56 57 58 138 139 140 142 149 156 157 157 204 206 210

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Figure 12.4 14.1 15.1 Risk Management Principles Ethical Decision Making Framework Recruitment and Selection Process XXIX Page 211 247 258

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Appendix =z Omr7 MD DA wD Pp H a Z2<dGQyHn Dp LIST OF APPENDICES Kotter’s 8-Step Change Model Sample 5-Year Development Plan, 2019-2024 Sample of Operational Plan 2019 Sample Mitigation Plan Sample Communication Plan Hospital Scorecard Sample WISN Analysis as Baseline for Decision-Making DOH Memorandum Circular No. 2016-0032 Sample Master Rotation Plan - Matrix Sample of Master Staffing Pattern Daily Every Shift Work Assignment Job Description of Nursing Personnel Republic Act No. 10968, An Act Institutionalizing the Philippine Qualifications Framework (PQF) Professional Regulatory Board of Nursing Resolution No. 21 Series of 2017 Amended Code of Ethics for Nurses Guidelines in the Establishment and Implementation of Agency Strategic Performance Management System (SPMS) Rules of Procedures in Handling Consumer Complaints for Violation of the Consumer Act of the Philippines (Republic Act No. 7394 Sample Quality Improvement Plan Transfusion Standard Operating Procedures Nursing Office Requirements Examples of Memorandum, Directives, Administrative Order Monitoring and Evaluation of the Nursing Service Nursing Service Bi — Annual Report Form Page 291 293 297 300 309 310 311 318 322 323 324 325 351 373 377 379 385 386 392 397 403 406

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PARTI THE ADMINISTRATION OF NURSING SERVICES

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The Administration of Nursing Services (This page is intentionally left blank.) Hospital Nursing Service Administration Manual

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The Department of Health 1 THE DEPARTMENT OF HEALTH The Department of Health (DOH) governs the Philippine health delivery system and is responsible for ensuring access to basic public health services to all Filipinos through the provision of quality health care, as well as regulation to providers of health goods and services. As such, the DOH is mandated to provide national policy direction and develop national plans for health programs and services, standards setting and guidelines on health, and licensing and regulation. Structurally, the Department of Health is composed of fifteen (15) central offices, seventeen (17) Center for Health Development (CHD) located in various regions, sixty-six (66) DOH Retained Hospitals, and 4 Government — Owned and Controlled Corporations (GOCC). There are 1,236 hospitals in the Philippines, 50% government hospitals and 50% private hospitals. As an offshoot of health devolution or known as Local Government Code of 1991 - RA 7160, out of 40% of the government hospitals, only seventy (70) hospitals are retained under the stewardship of the Department of Health. The aim of decentralization is to widen the decision-making authority of middle-level managers, enhance resource allocations from national to regional and local units, and improve the efficiency and effectiveness of health services management. Vision Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040. Mission To lead the country in the development of a Productive, Resilient, Equitable, and People-centered health system. Core Values e Integrity e Excellence e Compassion Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Strategic Goals e Better Health Outcomes e More Responsive Health System, and e More Equitable Healthcare Financing System These shall be achieved through the Four (4) Strategic Pillars: Financing, Service Delivery, Governance, and Regulation with the Plus of Performance Accountability. The FOURmula One Plus for Health (F1 Plus)is based on Administrative Order No. 2018-0014, or the STRATEGIC FRAMEWORK AND IMPLEMENTING GUIDELINE FOR FOURmula One Plus for Health (F1 Plus). THE FOURmula One Plus for Health (F1 Plus) Reforms builds on the decades of the health reforms such as the devolution of health care services in the 1991Local Government Code and the creation and expansion of PhilHealth. It is an expansion of the first FOURmula One Plus for Health (F1 Plus) under DOH Secretary Francisco T. Duque III. This new strategy seeks to strategically fill in the remaining gaps after the implementation of these reforms. The introduction of incremental revenues from the sin tax has provided significant gains in the Philhealth coverage and total health expenditure in the country. PhilHealth coverage is at 91%, by product of the government subsidies for the poor and senior citizens, funded by the sin tax revenues. Total health expenditures have also nearly doubled since 2010, amounting to 665 billion pesos. There is now significantly more money in health than ever befove and the total health expenditure are set to keep growing. Despite the significant increases in financial resources in the country, we have yet to see the corresponding improvements in health outcomes. Infant mortality rate was decreased by 4 per 1,000 live births between 2008 and 2017. Stunting growth in children under five increased to 33.4% in 2015. Percentage of children with basic vaccination has also decreased by 10% since 2008. Lastly, despite increases in PhilHealth budget and coverage the support value of PhilHealth, is still at roughly 50%, forcing patients to pay significant out-of-pocket expenses. Improvements in health outcomes have been marginal, despite meaningful increases in financing for health. Access to health services across geographic and socio economic divisions have been inequitable. Devolution has resulted in fragmentation of the health system, leading to a blurring of roles and accountability in the health sector, where responsibility is often passed on among different government agencies. The FOURmula One Plus for Health (F1 Plus) is the new strategic framework to attain the goals outlined by the Philippine government in the Philippine Development Plan, the sustainable development goals, and the AmbisyonNatin 2040. It builds and expands upon the original FOURmula One Plus for Health (Fl Plus) under DOH Hospital Nursing Service Administration Manual

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The Department of Health Secretary Francisco T. Duque III from 2005 to 2010. The new strategy expands the original Four Pillars while emphasizing the importance of performance accountability to all Filipinos.

1. FINANCING. To secure sustainable investments to improve health outcomes and ensure efficient and equitable use of health resources e Efficiently mobilize and distribute more resources for health

Innovative health taxes, efficient collection and progressive premium payments; income retention and fiscal autonomy; private health insurance and HMOs e Rationalize health spending

Population-based and personal insurable health services; pooling of funds; fixed co-payments and no-balance billing; multi-year budget e Focus financial resources towards high impact interventions

Focus on basic and essential; programs for the poor, marginalized and vulnerable; contributory PDP, SDGs and AmbisyonNatin2040 2. SERVICE DELIVERY. To ensure the accessibility of essential quality health services at appropriate levels of care e Access to quality essential health products and services

Essential health service package for all life stages and specialized services; public health strategies (disease-free zones, prevention and control; surveillance and monitoring; health promotion, health emergency) e Ensure equitable access to health facilities

Service Delivery Network (SDN)-responsive Health Facility Enhancement Program (HFEP), compliance to standard of care, step-down and chronic care e Ensure equitable distribution of Human Resource for Health (HRH)

Aligned with health facilities expansion; engage other Non- Government Agencies (NGAs) to ensure adequate production and quality HRH; equitable distribution (high compensation in Geographically Isolated and Disadvantaged Areas (GIDA) e Engage service delivery networks (SDNs)

Providers organized into SDN; families assigned to SDN; gatekeeping mechanisms; two-referral systems 3. REGULATION. To ensure high quality and affordable health products, devices, facilities and services e Harmonize and streamline regulatory systems and processes

One-stop shop, automation; 3" party accreditation; conflict of interest reviewed and managed; compliant with international standards; public information Hospital Nursing Service Administration Manual

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The Administration of Nursing Services e Innovative regulatory mechanisms for equitable distribution of quality and affordable health goods and services

Regulation-specific capacity building; national fee schedule; network licensing, risk - and outcome-based regulation, HRH production and distribution 4. GOVERNANCE. To strengthen leadership and management capacities, coordination, and support mechanisms necessary to ensure functional, people- centered and participatory health systems e Strengthen sectoral leadership and management

Stronger position on social determinants of health; participatory governance; readiness in possible shifts in government, Technical Assistance (TA) to LGUs based in Local Investment Plan for Health (LIPH) e Improve organizational development and management

Responsive organizational structure, staffing pattern and skill mix; competency-based learning and succession planning e Improve processes for procurement and supply chain management

Improve system for planning, forecasting, coordination and determination of health goods; strengthen procurement and logistics management system e Ensure generation and use of evidence in health policy development and decision-making

Culture of research and evidence use: improve access to data; Health Technology Assessment (HTA) insiitutionalization 5. PERFORMANCE ACCOUNTABILITY. To use management systems to drive better execution of policies and programs in the DOH while ensuring responsibility to all stakeholders e Improve transparency and accountability

Integrate tools and systems; performance accountability; scorecards e Shift to out-come based management approach

Regular monitoring and reviews; performance link to incentives FOURmula One Plus for Health (F1 Plus) will be the overarching framework which will require support from other government agencies and entities. The framework will also use the Performance use the performance governance system and other management systems to ensure that F1 will be properly implemented. Targets such as the National Objectives for Health and the Performance Scorecards will likewise provide indicators and goals for health stakeholders. Republic Act No. 11223 An act instituting Universal Health Care for all Filipinos, prescribing reforms in the Health Care System, and appropriating funds therefore. Hospital Nursing Service Administration Manual

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The Department of Health Universal Health Care (UHC), also referred to as KalusuganPangkalahatan (KP), is the “provision to every Filipino of the highest possible quality of health care that is accessible, efficient, equitably distributed, adequately funded, fairly financed, andappropriately used by an informed and empowered public. The DOH and Local Government Units (LGUs) shall endeavour to provide a health care delivery system that will afford every Filipino a primary care provider that would act as the navigator, coordinator, and initial and continuing point of contract in the health care delivery system: Provided, that except in emergency or serious cases and when proximity is a concern, access to higher levels of care shall be coordinated by the primary care provider and every Filipino shall register with a public or private primary care provider of choice. The DOH shall promulgate the guidelines on the licensing of primary care providers and the registration of every Filipino to a primary care provider. (Refer to RA 11223). Hospital Nursing Service Administration Manual

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The Administration of Nursing Services F1+ STRATEGY MAP Filipinos: are among the healthiest peaple in Southeast Asia by 2022, snd Asia by 2040. qo jead the country in the development ‘Of a Productive, Resilient, Equitable, and Peopie=centered health Systen: Better Health Outcomes, More Responsive Health System, and = More Equitable Healthcare Financing: FINANCING _ SERVICE DELVERY ‘REGULATION aren ERCURE EET STRENGTHEN LEADERSHIP. =| INVESTMENTS TO ACCESSIBILITY OF QUALITY AND Pe nacianan. ieeecueae IMPROVE HEALTH ESSENTIAL QUALITY MECHANISMS NECESSARY.TO EQUICOMES AND ENSURE HEALTH SERVICES AT PRODUCTS, DEVICES, ENSURE FUNCTIONAL, CEFFICIENT AND EQUITABLE APPROPRIATE LEVELS. FACILITIES AND - PEOPLE-CENTERED AND USE OF HEALTH RESOURCES OF CARE PARTICIPATORY HEALTH SYSTEMS © Stranger postion an suri deters of he: w Participatory gevertance increased collection from innovative health Laciities through fies Enhancenre: to standards of care 2 Development of health facilities for ‘step-down and chronic care. including rand compbaace to regional ané ieternational sta: development interventions linked to © Clear delineation in financing emerging technologies ° ue a2 sag succession planning and services: population-based and personst insurable health services Gi) “Ensure. ‘equitable distribation o @ Asingle fund to finance medical Tiina Bascurcectorttenitt aH) services for the poor Develop innovative — SO: and visdoerable © Alignment of HRH requirements with segulatory

© System improvement for planning. © No additional co-payment in health Facilities expansion esate forecasting, coordiriation and basic accommodation © Adequate production of quality HRH ia. es ; IST: A determination af heatth goods © Fixed co-payments for collaharation with other ‘equitable distribution © Strengthened procurement and logistics additional amenities government agencies olqualiy and management system © Multi-year budget scheme for @ Equitable disiribution of HRH through ifordabie health © Electronic procurement and lagistics priority programs competitive compensation and ‘goods and services Irsystem benefit packages . Focus finaricial resources ‘ Provision of regulation- “Ensure generation ana useot— towards high impact Ai Engage service delivery network: specific capacity building evidence in health policy

i {5DN5) arid teaoing Gevelioninent

Regul

7 a i health: ‘© Priority programs focused on: @ Public and private providers organized jab of prices ot eat i P goods aad Services thiough Culture of research and evidence use baste and essential primary core, hese SONS

a national fee schedule € Improved access te research and ter sheen ttl and, be aaa A © Adoption of network health data Papel a caep liceasing, isk and © integration of public and private SG, POR, and, * & te i sector data Natin 2020 mechanism at primary level of SOW € at CEH © Financing and ofheath =e y referral atall " services linked to performance tevels of SON ® BY. SS PERFORMANCE ACCOUNTABILITY dstitute tarippareset USE MANAGEMENT SYSTEMS 0 DRIVE ‘Shiftto outcome accountability measures Neer pevecorah oe pan niceaue: 2 matiagentent approach ® Integrated tools and systems

PROGRAMS IN THE DOH WHILE ENSURING — © Regular monitoring and © Performance accountability in af RESPONSIBILITY TO ALL. STAKEHOLDERS performance reviews health programs © Mechanisms linking petlormance Figure 1.1 F1 Plus Strategy Map Hospital Nursing Service Administration Manual

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The Department of Health Figure 1.1 presents the strategy Map of FOURmula One Plus for Health (F1 Plus). The vision of F1 Plus is that Filipinos are among the healthiest people in Southeast Asia by 2022and in Asia by 2040. The mission DOH is to lead the country in the development of a productive, resilient, equitable and people-centered health system. The DOH will be guided by the core values of integrity, excellence, and compassion in achieving the goals of ensuring better health outcomes, a more responsive health system, and a more equitable health care financing system. These will be achieved through the four strategic pillars of Financing, Service Delivery, Governance and Regulation with the addition of Performance Accountability. Hospital Nursing Service Administration Manual

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The Nursing Service 2 THE NURSING SERVICE The World Health Organization (WHO) experts’ committee on Nursing defines the Nursing Services as “‘the part of the total health organization which aims to satisfy the major objective of the Nursing Services, and that is - prevention of disease and promotion of health.” The Nursing Service constitutes the formidable backbone of the healthcare system both in numbers and its span of influence across the hospital spectrum. In almost all health care settings, the nursing group is composed of about 40% to 50% of the total workforce. These are the people providing 24/7 direct and indirect patient care irrespective of holidays and catastrophes. Considering the nature of the nursing undertaking in the organization, the group coordinates, collaborates, and integrates all the services — medicine, ancillary, pharmacy, dietary, finance, supply chain, maintenance, housekeeping, social service, and other patient and administrative support services. As the largest health care workforce in the clinical setting, the Nursing Service has a critical role in the provision of highest level of patient safety and quality care because they are at the forefront of patient care. The group is challenged to be creative and innovative in meeting the dimensions of quality: safe, effective, efficient, equitable, timely, and patient-centered care. Among the members of the health care team, Nursing Service Group is constantly present at the bedside monitoring patients for clinical deterioration or improvement, collaborating with physicians and allied health professionals, detecting near misses and errors, understanding care processes and facilitating solutions for weaknesses inherent in some systems, and interacting with patients and their families. Thus, Nursing Service is pivotal in significantly influencing patient clinical outcomes and satisfaction for the entire population it served and improving the health care system. Vision The Nursing Service envisions to be globally recognized in providing excellent health care and allied services to all Filipinos and other clients. Il Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Mission e Provide quality and culturally competent nursing personnel through research, learning and development in adherence to international standards and accreditation. e Guarantee equitable, sustainable, and quality healthcare e Establish performance standard e Participate in the development on improving local communities, self-reliance and participatory decision-making Philosophy e The Nursing Service believes and respects that patients have the right to receive holistic and quality care regardless of race, age, creed, gender, culture, religion, political affiliations and socio-economic status. e The Nursing Service is committed to assess and meet the physiological, physical, psychological, emotional, spiritual, social, rehabilitative, and financial needs of every patient served in the community. e The Nursing Service believes in compassionate, competent, and collaborative health care team providers to improve the delivery of health services to patients. e The Nursing Service is committed to life-long learning, research activities, and innovative strategies to improve the professional nursing practice and education. Core Values e Integrity e Commitment e Compassion Strategic Goal As service-oriented, dynamic, and empowered healthcare workforce, the Nursing Service shall fully support the provision of better health outcomes, more responsive health care systems, and good governance. Philosophy and Objectives of the Nursing Service The statement of objectives, mission or philosophy provides the basis for the nursing service existence. It explains the system of belief and values that determine the way by which the purpose should be achieved. Philosophy is a statement of belief and values of the organization. It addresses those issues which affect the nursing personnel. Goals and objectives are basically the same. However, goals are broader while objectives are more specific. 22 Hospital Nursing Service Administration Manual

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The Nursing Service The philosophy and objectives of the Nursing Service are congruent with that of the hospital and the DOH as well. Programs are developed and scheduled within a time frame to reach the set goals and objectives. The Nursing Service has developed a planning formula which may be used to daily duties or for short and long range projects. Objectives The objectives hereunder shall serve as a guide in the actualization of the strategic goal. 1. Enhance the standards of patient care based on evidence-based nursing practice and research. 2. Improve the health care service delivery for better patient clinical outcomes and satisfaction. Create a robust and effective governance framework. 4. Engage nursing staff in managing strategic goals through performance governance system. Rationalize the nursing human capital according to its changing needs. 6. Enhance the competency of the nursing service human resource through learning and development interventions. 7. Empower the nursing service human resource in performing varied leadership and management roles. 8. Strengthen collaborative relationship with other disciplines within the workplace, local and international settings. 9. Promote a positive practice environment for patients and health care professionals. 10. Upgrade communication and information technology systems to national standard. 11. Enhance systems and processes through technological advancement. 12. Intensify collaboration with affiliating schools for the related learning experiences of affiliates. 13. Conduct and participate in nursing research towards evidence-based professional nursing practices. uo Nn Conceptual Framework The framework of the Nursing Service administrative process shows the functions and respective roles of the Nursing Service administrators. A clear understanding of this process and how they are applied in different organization levels are necessary to achieve the objectives and goals set by the agency. As an administrator, the Chief Nurse basically performs the major management functions: namely: Planning, Organizing, Staffing, Directing, and Controlling. These 13 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services functions entail the utilization and management of human, financial, physical, and information resources. The effective performance of these functions contributes to the attainment of the organization’s goal of quality patient/client care. Planning is the first management function that primarily deals with the future. It entails forecasting or setting the broad outline of the work to be done. It directs our thinking toward what we expect to do, why it will be done, where it will be done, when we expect to do it, how it will be done, and who is going to do it. Organizing involves the identification of duties to be performed, a grouping of these duties to indicate division of labor. It also entails assignment of authority according to the line, staff or functional relationships that will exist between individual jobs and total organizational units. Staffing functions consist of identifying work force requirements, recruiting, interviewing, selecting, hiring, promoting, appraising, and orienting staffs that tasks are accomplished effectively and efficiently. It also involves filling and keeping filled, the positions in the organization structure. Scheduling, staff development, employee socialization, and team building are also often included as staffing functions. Directing is the manner of delegating assignments, orders and instructions to the nursing personnel. It is the heart of management process. The elements of directing include supervision, delegation, communication, teamwork and collaboration, problem solving and decision making, motivation, bench marking. conflict management and change management. Controlling is measuring performance against goals and plans, showing where deviations from standard exist and helping to correct deviations from standards. Controlling functions include performance appraisals, fiscal accountability, quality control, and professional and collegial control. A management system is a set of policies, processes and procedures used by an organization to ensure that it can fulfil the tasks required to achieve its objectives. These objectives cover many aspects of the organization's operations. 14 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services sqp0s payne fo juamanoyy ayp 40f SsaOdg MAMISOUT|Y SUSAN] WEY ['T ARBLT E S09 viva Stan wn Hospital Nursing Service Administration Manual 16

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The Nursing Service NURSING SERVICE STANDARDS, POLICIES AND PROCEDURES Nursing Service Standards created by the various professional organizations and governmental agencies concerned with quality health care can be of immense values to the nursing administrator by serving as a framework for departmental evaluations. The meaning of standards must be clear to those who are controlling them. Standards maybe stated in terms of the highest or optimal level of attainment desired, the minimal or baseline level. The Philippine Professional Nursing Practice Standards (PPNPS) The primary purpose of nursing standards is to promote, guide and direct professional nursing practice. The nursing standards will be used by the individual nurses, the public, the employers, the regulatory boards, the academe and other stakeholders (College of Nurses of Ontario, 2002; Registered Nurses Association of B.C. 2003). Development of Nursing Standards in the Philippines Legal Bases The impetus in the development of nursing standards emanated from article III, Sec. 4 (h) of Republic Act No. 7164 (the Philippine Nursing Act of 1991) which enumerated the powers, duties and functions of the Professional Regulatory Board of Nursing (PRBON). Among others, the PRBON shall “Promulgate decisions or adopt measures as may be necessary for the improvement of the nursing practice for the advancement of the profession”. Republic Act No. 9173, the Philippine Nursing Act of 2002, Section 9 (c) states that the Professional Regulatory Board of Nursing s empowered to “monitor and enforce quality standards of nursing practice in the Philippines and exercise the powers necessary to ensure the maintenance of efficient, ethical and technical, moral and professional standards in the practice of nursing into account the health needs of the nation.” Structure: Organization of Nursing Service There is an organized Nursing Service Division which is directed by qualified nurse administrator. Criterion: Philosophy The philosophy articulates a vision and provides a statement of beliefs and values that direct one’s practice. It should be written, included in appropriate documents and reviewed periodically. The Nursing Service has a written set of philosophy. These reflect the standards prescribed by the nursing profession and provide Hospital Nursing Service Administration Manual 17

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The Administration of Nursing Services direction towards the development of programs to improve the delivery of nursing care. Standards are desired quantity, quality or level of performance that is established as a criterion which worker performance will be measured. Philosophy is a written statement that reflects organizational values, vision, and mission. Objectives are statements of achievements specific to abilities within the organization. Administration is the direction, coordination and control of many persons to achieve some purpose or objective. (L.D. White, 2013) Herbert A. Simon (2013) points out, in its broadest sense, administration can be defined as “the activities of groups cooperating to accomplish common goal”. Administration has to do with getting things done, with the accomplishment of defined objectives (Luther Gullick, 2013). The Nursing Service Administrator: Plans, organizes and supervises the Nursing Service in order to provide quality nursing care to patients. Coordinates all activities of Nursing Service department with other services. Monitors and evaluates nursing personnel and activities, and recommends improvements to ensure the standards are met. Formulates and recommends policies for the improvement of patient care. Conducts meetings and services programs as a venue to discuss issues, updates in new technologies, and other matters for Nursing Service personnel. Participates in meetings as representative of Nursing Service Personnel. Participates in the preparation of the budget proposal especially in the area of Nursing Service. Prepares and submits Nursing Service reports as required. Approves procurement plan to ensure complete hospital supplies and equipment. Initiates training, research and other creative endeavor. Collaborates with the Medical Center Chief in developing programs, policies, budget and other plans for these needs of the Nursing Service and the improvement of patient care. Performs other related functions as maybe assigned. 18 Hospital Nursing Service Administration Manual

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The Nursing Service Nursing Service Policies Policies are broad guidelines for the managerial decisions that are necessary in organizational and departmental planning. Policies explain how goals will be achieved and served as guide that defines the general course and scope of activities permissible for goal accomplishment. They serve as a basis for future decision, actions, health coordinated plans, control performance, and increase consistency of actions by increasing the probability that different managers will make similar decisions when independently facing similar situations. Policies are usually developed by a policy committee. At the nursing division level, the committee will be represented by nurse managers and top nursing management. Nursing Service Policies exist for standardization and as a source of guidance of the nursing staff. As guidelines, they give nurse managers inputs into nursing activities of each unit, ward and clinic in which nursing personnel practice. Guiding Principles e All personnel affected by policies or practices should share in their formulation through discussion of proposals and formulation of recommendations. e Personnel policies for all hospital employees should be approved by the governing body. e Within this frame of reference, practices specific for nursing personnel may be developed and approved by the Medical Center Chief. e All approved policies and practices should be in writing. e The general administration of Nursing Service personnel policies and practices is the responsibility of the Chief Nurse. e Personnel policies and practices should be kept up-to-date. Steps in Developing a Policy e Policy Determination. Creation of Policy Committee. Development of policy from appropriate sources of information. Review of the policy draft. Circulation of the draft policy to other appropriate units or services. Final approval by policy committee and signature of Chief Nurse and Medical Center Chief. e Distribution with appropriate communication. There are three general areas in nursing that require policy formulation: e Areas in which confusion about the locus of responsibility might result in neglect or non- performance of an act necessary to a patient’s welfare; e Areas pertaining to the protection of patients and families’ rights e.g., right to privacy, property rights; and Hospital Nursing Service Administration Manual 19

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The Administration of Nursing Services e Areas involving personnel management and welfare. Characteristics of Good Policies e Policies can be implied or expressed. Implied policies are not directly voiced or written but are established by patterns of decision. e Fairness is attributed to the application of policy. Consistency is important, since inconsistency introduces uncertainty and contributes to feelings of bias, preferential treatment and unfairness. e Policies should be written and understandable. e Policies should be comprehensive in scope, stable, flexible, so that they can be applied to different conditions that are not so diverse that they require different sets of policies. Reasons Why a Policy cannot be implemented: e Ifthe policy fails to take into account, the constraints within a situation. Example. If a policy which requires isolation individuals with wound infection would not be implemented on an area in which there exists no such accommodation. The Nursing Service Policy Manual A Nursing Service Policy Manual is a definite course or method of action that guides and determines present and future decisions regarding the safe delivery of patient care. The manual becomes a tool tor orienting staff, a reference when unexpected problems arise, a foundation on which to develop administrative procedures and a firm basis for discussion when differences occur. Some manuals contain a combination of policies and administrative procedure. Others are limited to policies only, but whatever will work best for the service should be included. A yearly periodic review of policies and as the need arises, is necessary to evaluate their effectiveness and workability. Problems in their implementation are discussed including verification as to whether these are being followed. Should changes be necessary, all personnel should be informed. Policies fall into three main categories: e Those that apply to patients; e Those that apply to Personnel; e Those that apply to the environment in which patients are cared for and where personnel work. 20 Hospital Nursing Service Administration Manual

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The Nursing Service Interdepartmental Policies Interdepartmental Policies are developed in keeping with overall hospital policies, thus ensuring unity and harmonious relationships among departments. The Nursing Unit will endeavor to make good use of the professional and technical services to render help to the patient. This requires a clear understanding of how these services can be carried out smoothly for the betterment of all concerned. Coordination of all activities in obtaining the same final goal may be made through the use of written policies. Nursing Procedures Nursing Procedures are series of steps followed in a regular definite order to perform a given activity, the how of a given activity. In addition to policies, a written and current nursing procedures manual should be available to all nursing personnel. Procedures outline a standard technique or method for performing duties and serve as a guide for action. Procedures are detailed plans for nursing skills that include steps in proper sequence. Purposes e Procedures are used for communication, understanding, standardization and coordination. e They are referred to for review when an employee has not done a procedure for some time. e They are used to teach and evaluate new employees and student affiliates. e To orient new employees to distinguishing characteristics of an institution’s procedures. e To update employees in developing technologies. Nursing procedure manuals should be available in each unit to familiarize nurses with the common nursing procedures utilized in that unit. Nurses may have graduated from different colleges of nursing and may not have been familiar with the procedures during their student days. Procedure manuals usually have a general format. These include definition, purpose, materials needed, proper requisitioning of supplies, proper disposal of used equipment, and pertinent information or precautions to take, legal implications, expected responsibilities of the nurse and the patient, and proper documentation when such is completed. Precautions should include watching for untoward signs and symptoms related to the procedure. Policies and procedures are reviewed, revised as necessary, and dated to indicate the time of the most recent review. 21 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Utilization and Revision of Policies and Procedures Each department utilizes the policies and procedures particular to each service. These are updated and/or change as needed with the collaboration of the various members of the health team. Distribution New or revised materials should be distributed as soon as possible after it is approved and ready for distribution. A memorandum should be attached to any manual material that is distributed. It should contain: date of distribution, an explanation of the subject and direction for posting, indexing, adding, deleting, and filing. Even if the material is hand-delivered and the instructions are carried out by the person who delivers the materials, the memorandum should be posted on the departmental bulletin board as a reminder that new material is to be implemented. Implementation of New Policies and Procedures A new manual or revised individual policies and procedures bring about changes, sometimes suddenly. If personnel are not prepared for these changes, discord, confusion and resentment may result. Implementation includes both the understanding that a mandate exists and that a positive approach to change is important. e Distribute new or revised policies and procedures to the entire staff at the same time. Ask everybody to read and demonstrate that they understand and can perform them. Their signing that they have read and do understand the information places the responsibility on them. e Hold a conference or meeting in small department to discuss and demonstrate new policies and procedures. This can be done as a part of regular meetings that are held weekly or monthly. e Have a procedure demonstration day. All units are given a copy of the procedures so that they can follow. Return demonstration from the group are also used to reinforce learning. e Place the complete manual on each unit. Discuss one or two revised or new policies and procedures at each conference meeting until the manual has been reviewed by all employees. e Ask personnel of one nursing unit to demonstrate a procedure to another unit, this continues until all units have participated in a learning situation. 22 Hospital Nursing Service Administration Manual

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The Nursing Service Advantages of Sound Personnel Practices in Nursing Service Administration To the Medical Center Chief Sound practices give assurance to the Medical Center Chief that: The plan for Nursing Service is founded on good professional standards and is in harmony with the policies of the hospital in general; The budget for Nursing Service personnel is soundly conceived; There is satisfactory relationship between the written job description and the qualification of the persons requested in the Nursing Service budget; The Personnel practices for Nursing Service can be defined in terms of existing supply and demand and the general employment conditions for comparable personnel; e Explanation and discussion of the written policies and practices are included in the orientation of all new Nursing Service employees. To the Chief Nurse Sound personnel practices reflect an analysis of the total job of nursing in accordance with the types of activities to be performed, the quality of service to be maintained, and the purposes for which the hospital exists. In a sense, they represent an informal contract between the hospital and the employees. The written conditions of employment as well as personnel practices are discussed with the employees. They have the following distinct advantages: Each category of personnel is identified through clear job specification; The qualifications for each category are defined in terms of the responsibility to be assumed; Personnel may be selected objectively on the basis of job specifications already outlined; These provide for the Chief Nurse easy solution to problems presented by employees that fall within the area of Nursing Service; These afford support to the Chief Nurse when presented by individuals, within or outside the Chief Nurse’s organization, to screen or deter employment of unqualified persons; These guarantee conditions of employment which have been designed to promote job satisfaction for the employee; Turnover of staff cannot be attributed to unrefined personnel practices; These can be used as objective points of discussion when coordinating activities within the group of nursing personnel. The Chief Nurse knows that sound policies and practices, developed through the cooperative actions of the employer and employees create continued loyalty to the institution. Hospital Nursing Service Administration Manual

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The Administration of Nursing Services To the Employee Written personnel policies and practices provide for the employee: e A job description which makes it possible to determine the satisfaction offered through a particular position; e Ascale for weighing his qualifications for a position in the light of the written specifications; e A basis for study of conditions of employment, which following verbal explanation by the employing officer, is a safeguard against the possibility of misinterpretation; e A means of judging opportunities which the institution may offer for the future. The personnel policies for hospital personnel under the Department of Health are governed by provision under Republic Act 2260 of the Civil Service Law and Rules and Regulations Implementing the Labor code of the Philippines, Administrative and Department Orders, within the provisions of these general policies. The Nursing Service personnel policies are administered by the Chief Nurse under the supervision of the Administration with freedom to establish procedures and techniques which would provide for their effective functioning, and promote efficiency and improvement of morale. It is incumbent upon nursing personnel to follow lines of authority, to support policies, to observe regulations, to be loyal to the institution and give the hospital the best of service of which they are capable. 24 Hospital Nursing Service Administration Manual

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Planning the Nursing Service 3 PLANNING THE NURSING SERVICE At the end of this chapter the Chief Nurse and Nurse Managers shall be able to: Discuss planning as a management function Formulate Strategic Plan Create Operational Plan Design Succession Plan Describe the importance of Planning and Budgeting the Nursing Service Discuss the budgetary plan and take responsibility in monitoring and control of all expenditures incurred Planning is designed for the nurse administrators who are seeking more effective means of improving current and future performance. It offers principles of planning and decision making guides in nursing practice. It deals with those aspects of planning that directly affects the nurse administrators on a personal as well as organizational level. It is the first management process defined by Fayol as making a plan of action to provide for the foreseeable future. It is a continuous process, beginning with the setting of goals and objectives and then laying out a plan of action for accomplishing them, putting them into play, reviewing the process and the outcomes, providing feedback to personnel, and modifying the plan as needed. (Roussel, 2006). Importance of Planning Planning is a principal duty of every nurse manager in all management levels for the following reasons: e Ensures alignment of nursing unit/department and financial plans with the strategic plan. Thus, increases the probability of achieving the organizational goals, vision, and mission. e Establishes a framework for decision making consistent with top management objectives. e Forces analytic thinking and evaluations of alternatives, thereby improving decision-making. e Ensures safe quality care through awareness of individual responsibility and accountability. Hospital Nursing Service Administration Manual 25

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The Administration of Nursing Services Improves communication and team collaboration through people involvement in planning activities. Provides a basis for managing organizational and individual performance. Ensures cost-effectiveness in the utilization of resources, facilities, utilities, and services. Improves organizational systems and processes. Discovers the need for change that leads to create new services and productivity. Manages risks and copes with crisis situations. Characteristics of a Good Plan The characteristics of a good plan are adapted from the standards of planning process by Roussel (2006). The plan is written. It defines the nursing business. It contains both general goals and specific objectives. It defines strategies. It supports the mission. It details forecasted activities for a year & longer than one year. It has been developed with inputs from clinical nurses and line managers. It addresses resources such as personnel and facilities. Changes are evident. Financial plan is included. Needs are identified and supported. Priorities are included. Timetables are listed. It is based on current data analysis. It assesses both strengths and weaknesses. It derives from a good nursing management information plan. It used and modified consistently Types of Planning 1. Strategic Planning is a broad continuous systematic process that emphasizes assessment of the organizational environment both internally and externally such as economic, political, social, and technological factors. It is a management tool that helps organizations set long-term goals, a risk-taking decision with knowledge of their effects in the future, and evaluating the outcomes through reliable feedback mechanism. It focuses on performance improvement and utilizes strategies to accomplish the organization’s desired outcomes. Operational Planning is a detailed work plan or written blueprint in which the objectives of a nursing unit/department are put into measurable actions. It 26 Hospital Nursing Service Administration Manual

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Planning the Nursing Service provides a clear picture of how a team, nursing unit or department will contribute to the achievement of the organization’s strategic goals. It is also known as a management plan. Some categorical areas for objectives are: patient satisfaction, patient safety, internal process, staffing, training and education, research, and financial. 3. Nursing Succession Planningis a strategy for identifying and developing potential future nursing leaders who can replace them in case of retirement, separation from service or any inevitable circumstances to ensure continuity of leadership and services. Five-Step Process in Succession Planning Identify Key Areas and Positions Identify Capabilities for Key Areas and Positions Identify Interested Employees and Asses them Against Capabilities Develop and Implement Succession and Knowledge Transfer Plan Evaluate effectiveness eae se Kotter's 8-Step Change Model One of the most widely used change management strategies has been created by Dr. John Kotter, the founder of Kotter International and a recipient of numerous awards in the fields of business, leadership, and change. Commonly referred to as Kotter's 8- Step Change Model, this change management strategy describes eight steps organizations must take to enhance their ability to implement change initiatives successfully(See Appendix A, Kotter’s 8-Step Change Model). Implementing Change Powerfully and Successfully When you plan carefully and build the proper foundation, implementing change can be much easier, and you'll improve the chances of success. If you're too impatient, and if you expect too many results too soon, your plans for change are more likely to fail. Create a sense of urgency, recruit powerful change leaders, build a vision and effectively communicate it, remove obstacles, create quick wins, and build on your momentum. If you do these things, you can help make the change part of your organizational culture. Hospital Nursing Service Administration Manual 27

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The Administration of Nursing Services | STEP 1. Identify Key Areas and Positions Keyareas and positions are these that are critical to the onsanization’s operational activities and strategic objecties. 1 Identifyinhich positions, fleft vacant, woul make it verydifficultte achieve ourent and future business goals 1 _Identifywhich positions, fleft vacant, would be detnmental to the health, safety, or secuntyof the Philippine public. STEP 2. dentify Capabilities for | | Key Areas and Positions To edablish selection criteria, focus employee development efforts, and set performance expectations, you need to determine the capabilities required forthe ke yareas and positions identified in Step 1. (1 Wentifythe rekvant nomtedye, skills fncluding language), abilties and competencies needed to achiewe husness goals. OO Use the Key Leadership Gompetencies profile 1 Inform emphyees about keyareas and positionsand required capabilties | STEP 3. Identify Interested Eniployees and Assess Them Against Capabilities Detennine who is ntetested hh and has the potenthi to fill ke yareas and positions. O Discuss careerplans and interests with emphyees. 0 Wentifythe keyareas and positions that are wherable and the candidates who are readyto advance or whose skills and competencies could be devebped within the required time frame. : 1 Ensure that a sufficient nurnberof bilingual candidates and members of designated groups are n feedergroupsfor keyareas and positions. | STEP 4. Develop and Implement Succession | | and Knowledge Transfer Plans Incomorate kaming, traning, development and the transferof comorate hnowledge into your succession planning and management O Define the Eaming, training and development experiences that your organization requires for kadership positions and other key areas and positions. DLink employees’ leaming phnsto the noukdge, skills (including language) and abilities required for curent and future roks. O Discuss with emphyees howthey can transtertheir comorate hiowdedge . STEP 5. Evaluate Effectiveness nd raonitor your succession plnning and management effortste ensure the following: O Succession phnsforall keyareas and positions are devehped; Ol Keypositionsare filled quickly; Ol Newempbyees h key postions perform effecthely; and 1 Members of designated groups are adequatelyrepresented i feeder groupsfor keyareas and positions. Figure 3.1 Five-Step Process in Succession Planning Table 3.1Differences between the Strategic Planning and Operational Planning Basis of Comparison | Strategic Planning Operational Planning Scope General plan Specific plan Time Frame 3 -5 years 1 year Focus Goal setting process | Detailed information Goal/Objective Broad Specific Responsibility Top management Middle and Line management Approach Downward Upward 28 Hospital Nursing Service Administration Manual

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Planning the Nursing Service The Strategic Plan is known as the general plan that serves as a guide in positioning the organization for the pursuit of its, vision, mission, and goals. It is a long-term plan, wherein the time frame is usually 3-5 years. It is an analytical process, which examines the organization’s internal and external environment to define its desired future and priorities that will lead towards the achievement of its ultimate goals. The goals in strategic plan are stated broadly. The development of strategic plan is the responsibility of top management. It is a downward approach in which directions, guidelines, information, and fund processes are communicated to lower management to assist in the formulation of their operational plans. Operational Planning is a specific plan that supports the strategic plan by implementing its strategies, projects and programs. It provides detailed information to direct its people to perform the day-to-day tasks and activities in running the nursing unit/organization. The operational plan objectives are specific. These are concrete statements that nurse managers seek to accomplish in terms of results. It includes the what (tasks to be undertaken), who (person responsible), when (timeline for task completion, and how much (amount of financial resource to carry out the task). The formulation and implementation of an operational plan is the responsibility of middle and front-line managers and it’s done yearly. Operational planning is an upward approach because team members are actively involved in the planning process. They are encouraged to develop personal to-do list necessary to reach the targets or milestones of their nursing units (See Appendix B, Sample 5-Year Development Plan, 2019-2024; Appendix C, Sample of Operational Plan 2019). Steps in Strategic Planning Generally, hereunder are the steps in strategic planning:

1. Know the strategic direction-goals It is important to know the strategic direction of the organization for it is a critical enabler for governance and framework for decision-making. It is an organized and innovative course of action that leads to the achievement of the organizational long-term goals. Strategic direction is always anchored with the established organizational vision, mission, philosophy, and core values. In healthcare, strategic goals may focus on patients/clients safety and satisfaction, staff learning and growth, quality care, technological advances, innovative services, process efficiency, and financial viability.
2. Perform environmental scanning Environmental scanning is a process that systematically surveys and interprets relevant data to identify internal strengths and weaknesses, and external opportunities and threats. Assessment of the internal environment may include Hospital Nursing Service Administration Manual 29

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The Administration of Nursing Services occupancy rate, population trends, length of patient stay, patient acuity, quality patient care, staff attrition and retention rate, service utilization, process efficiency, information system and financial resources. The external environmental factors may include statutory and regulatory laws, healthcare trends, accreditation, technology advancement, industry competition, economic, political and market factors. Collect and analyze data Data collection is the process of gathering and measuring information on targeted variables in an established systematic operation. On the other hand, analysis of data is the process of systematically applying statistical and logical techniques to describe, illustrate, and evaluate gathered data. Nursing data may include patient census, cases, mortality and morbidity rates, and acuity of care; staff retention and attrition; nursing sensitive quality indicators such as hospital acquired pressure ulcer and infections Catheter — Associated Urinary Tract Infection (CAUTI), Central Line Associated Blood Stream Infection (CLABSI), Ventilator — Associated Pneumonia (VAP), and medication error and fall rates. Set specific objectives Setting specific objectives is a process of identifying something that the nurse manager would like to accomplish in a given period of time. It is written in a clear and concise manner and it must be specific, measurable, attainable, realistic, and time bounded. Example of nursing unit specific objective is to reduce the medication error rate by 5% at the end of the year. Determine programs and activities Programs and activities are the implementation or execution phase of the management plan. They are the means by which organizational goals and objectives are achieved. Examples of programs are related to: total quality management, patient safety, patient satisfaction, infection prevention and control, training, education and research, and nurse certification. Set key performance indicators Performance indicator is any metric or data used to measure the achievement of the organizational performance. It is based on standards determined through evidence-based research literature or consensus of experts when evidence is 30 Hospital Nursing Service Administration Manual

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Planning the Nursing Service 10. unavailable. It is a measurable value that demonstrates how effectively an organization is achieving its key objectives. There are four perspectives of a performance indicator set to provide a comprehensive view of the organizational performance according to Norton and Kaplan. These are: e Customer user — measures how organization meets the assessed needs and expectations of the customer users. Example is patient clinical outcome and patient satisfaction rates. e Internal Processes — measures the key organizational processes identified as necessary for a high quality and effective service. Example is compliance rate to policies, procedures, protocols, and standards. e Learning and Growth — measures the organization’s systems and people to quantify learning and improvement. Example is the learning and growth of people through training and education programs. e Financial — measures the efficient use of resources to achieve the organizational objectives. Example is financial revenues and expenses of every nursing unit. Identify the person responsible Person responsible or known as a project/program champion is a team leader who provides psychological, moral, physical supports and resources to the members for the execution of the assigned specific program. The tasks should match with the abilitics of the identified person responsible. Set the time frame Time frame is a set period of time to accomplish the program or project and other related activities. It includes specific month and date in a year. Forecast the budget Budget is a detailed financial plan for carrying out the programs and activities the nurse manager wants to accomplish for a certain period of time. The Chief Nurse should actively coordinate with finance and planning officers and other stakeholders pertaining to budget preparation, requirements and budget allocation. Identify the risks Risk identification is a process of determining the undesirable events such as threat of damage, injury and liability loss, and evaluating its impact that could potentially prevent the program of the organization from achieving its Hospital Nursing Service Administration Manual 31

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The Administration of Nursing Services 11. 12. 13. objectives. It aims to mitigate the risks and limit their impact through risk management program. Examples of potential risks in healthcare are related to patient safety, legal, media, cyber, calamities, manpower, and financial. Create a mitigation plan Mitigation plan is the process of developing options and actions to enhance opportunities and reduce threats to organizational goals. The purpose of mitigation plan is to curtail the effects of possible threats or hazards if not totally eliminate the adverse impacts of the known or perceived risks inherent in a particular undertaking, even before any damage or disaster takes place. It encompasses activities that surround prevention and mitigation of events to reduce poor outcomes, or financial and professional losses. Example of mitigation plan is crisis management plan and emergency preparedness plan in case of communicable disease outbreak, fire, and earthquake (See Appendix D, Sample Mitigation Plan). Monitor and evaluate the results Monitoring and evaluation is a process of tracking the progress and accomplishment based on the set goals and objectives. It utilizes tools to measure the actual performance based on the established indicators Examples of monitoring tools are: Safety Checklist, Competency Analysis, IPCR, DPCR, Nursing Audit, Performance Budget Utilization, and Gantt Chart. The color-coded reporting is utilized to monitor the progress of the management plan such as a) green - on progress, b) yellow - delayed, c) red - no progress/major issues identified. Develop a communication plan Communication plan is a policy-driven approach to provide constituents with information about the plan, which contains the specific programs and activities. Communication plan is crucial to program success. It formally defines who should be given specific information, when that information should be delivered, what communication channels will be used, and to whom the communication should be delivered or cascaded (See Appendix E, Sample Communication Plan). 32 Hospital Nursing Service Administration Manual

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Planning the Nursing Service 14. Disseminate the approved plan It is the process of cascading the approved management plan usually through memoranda and unit/department meetings. Steps in Planning the Nursing Service A. Forecast Forecast describes the ultimate conditions or projections that provide the general incentive and direction to planning. It anticipates the environment or setting where the plan will be operationalized such as: e The hospital — this includes the type of hospital served (Level 1, Level 2, Level 3,); the kind of service it offers (general or special) its philosophy mission and goals and categories of their budget (national or local). e The community it serves — this includes the kind of people served their needs, expectations, literacy rate, economic levels, employment rates, demographic statistics, cultural values, beliefs and services available in the community. e The goals of care — vary according to the needs of the community, agency, trends in technology and in changing concepts of the nurses’ roles and functions. Forecast must be supported by facts, reasonable estimates and accurate reflection of policies and plans. In planning for the nursing service, assess the quality being given, clarify the activities that will benefit in achieving both the long and short range goals. B. Define the philosophy and objectives of the Nursing Service The statement of objectives, mission or philosophy provides the basis for the nursing service existence. It explains the system of belief and values that determine the way by which the purpose should be achieved. C. Identify and develop strategies, programs/projects activities. Set the time frame. Prepare the budget Programs are developed and scheduled within a time frame to reach the set goals and objectives. It has developed a planning formula which may be used to daily duties or for short and long range projects. Effective planning involves answering certain questions that constitute the basic elements of this activity, using the question technique with “why” as the common denominator: 33 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services What action is necessary? Why? Where will it take? Why? When will it take place? Why? Who will do it? Why? How will it be done? Why? Since planning requires forecasting, generalization, analysis, detail and specification, it precedes action and should systematize and provide the basis for such action. D. Establishing Nursing Service Standards, Policies and Procedures Nursing Service Standards created by the various professional organizations and governmental agencies concerned with quality health care can be of immense values to the nursing administrator by serving as a framework for departmental evaluations. The meaning of standards must be clear to those who are controlling them. Standards maybe stated in terms of the highest or optimal level of attainment desired, the minimal or baseline level. Although some institutions develop their own standards of nursing practice, the Standards of Nursing Practice and Nursing Service Administration formulated by a joint committee of the Association of Nursing Service Administrators of the Philippines and the Philippine Nurses Association which was first printed in 1981, Philhealth Benchbook, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are good references. Standards are desired quantity, quality or level of performance that is established as a criterion which worker performance will be measured. Policies are broad guidelines for the managerial decisions that are necessary inorganizational and departmental planning. Procedures are series of steps followed in a regular definite order to perform agiven activity, the how of the activity. Tools in Planning There are many effective tools used to assist in planning. The most commonly used in health care organizations are SWOT Analysis, Pestel or Pestle Analysis, Balanced Score Card and Steeple Analysis. 34 Hospital Nursing Service Administration Manual

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Planning the Nursing Service A. SWOT Analysis SWOT is an acronym for Strengths, Weaknesses, Opportunities, and Threats. It is a framework for analyzing and identifying the internal and external factors that can have an impact on the achievement of the organizational goals and objectives. A SWOT analysis is a useful method that can help you to identify the strengths, weaknesses, opportunities and threats relating to your shared purpose or an aspect of care that you want to improve. A SWOT analysis is most effective if it is done in collaboration with the people who have created the shared purpose. A SWOT analysis is a tool that can provide prompts to the managers, clinical leads, nurse tutors, nurse mentors and staff involved in the analysis of what is effective and less effective in clinical systems and procedures, in preparation for a plan of some form (that could be an audit (CQC), assessments, quality checks etc.). In fact aSWOT can be used for any planning or analysis activity which could impact future finance, planning and management decisions. It can enable you (the management& clinical staff) to carry out a more comprehensive analysis. Strengths are internal attributes that are likely to have a positive effect or enabler in the achievement of the organizational objectives. Examples are: extraordinary reputation on health care services, clinical expertise of staff, high-performing team, and supportive leadership. Factors that have encouraged exceptional organizational performance are strengths. Examples include using state-of-the-art medical equipment, focusing on healthcare improvement, investments in healthcare informatics, highly trained medical personnel and top-notch medical services. Weaknesses are internal attributes that are likely to have a negative effect or barrier in the achievement of the organization objectives. These are areas that need improvement and may include: poor patient care, understaffing, lack of quality procedures, and vague organizational direction — goals. Factors that affect healthcare quality or increase healthcare costs are weaknesses. Some examples are outdated healthcare facilities, fluctuation in the continuity of care due to poor communication, insufficient management training, poor use of healthcare informatics, and lack of financial resources. Opportunities are external conditions that promote achievement of organizational objectives. These are the elements that the nursing department/organization could exploit at their advantage. Examples are: absence of dominant competitors, advancement in technology, academic medical center/training specialty hospital. New business initiatives available are considered opportunities by healthcare organizations. Some examples include collaborations with different healthcare organizations, development of 35 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services new healthcare programs, increased funds for better healthcare informatics, and so on. Threats are external conditions that challenge or threaten the achievement of organizational objectives. These are the elements that could cause trouble to nursing department/organization. Examples are: low retention rate, lack of highly skilled nurses, low salary, and statutory laws affecting the nursing practice. Factors that could harm the performance of healthcare organizations are considered threats. Examples include economic or political insecurity, increased demand for expensive medical technology, budget deficits on state and federal level, and increased pressure for reduction in healthcare costs. Steps to Follow for SWOT Analysis in Healthcare SWOT analysis was originally designed to provide a thorough analysis of businesses in other industries, but its many benefits have prompted its use in healthcare organizations as well. The first step of SWOT analysis in healthcare involves the compilation and assessment of key data, which might include the community’s health status, present status of medical technology, or the sources of healthcare funding. Once the appropriate (and correct) data has been composed and analyzed, the capabilities of the organization are evaluated. In the second step of SWOT analysis in healthcare, the data collected is organized into four categories, which are: strengths, weaknesses, opportunities and threats (SWOT). The strengths and weaknesses of the organization are internal factors, while opportunities and threats normally are a result of external factors playing their part. Third step of SWOT analysis in healthcare involves developing a SWOT matrix for each business option that is under consideration. In the fourth step of SWOT analysis in healthcare, the analysis derived is incorporated into the decision-making process as it determines which option will best suit the overall strategic plan of the organization. Four (4) Rules to Keep in Mind While Conducting SWOT Analysis in Healthcare 1. Be Realistic. Always be unbiased when collecting and evaluating data. 2. Avoid Complexity. Keep it short and simple to avoid over-analyzing problems. Analyze Rationally. Compare your plans only with key competitors to get a better idea of whether the plan is better or worse than theirs. Attain Change. Strategic plans should be updated as soon as problems are identified so that appropriate steps towards directional change can be taken. 36 Hospital Nursing Service Administration Manual

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Planning the Nursing Service STRENGTH WEAKNESS Qualified Nursing Staff Educational and Learning and Development Interventions provided Availability of Specialty and Subspecialty departments where Nursing Staff performs complex and comprehensive Nursing Care Procurement and Installation of state of the Art Equipment 85% Nurses certified for competency program of different specialty In-house research participation Established PETRO for Nursing Services Active Participation in Different Hospital Committees Direct Participation in Hospital Planning Accommodation and provision of Learning and Learning Development Needs as per TNA results Availability of Nursing Leaders and other potential leaders Movement of staff from one area to another due to exigency of service and needed outside of the hospital responsibilities and commitments Newly hired nurses lack competencies and necessary clinical exposure Lack of knowledge and skill in the operation of the emerging technologies procured by the hospital Ineffective time management to participate in more research Limited budget for Learning and Development Intervention needed by Nursing staff Restricted time to fully act on their duties in different committees Limited budget to accommodate End users documented needs OPPORTUNITIES THREATS External Learning and Development Grants for the Nurses Manpower Augmentation as per DOH and DBM approval External researches participation (Podium and International/Local presentation) Membership to Nurses and other Nursing Personnel to Professional Organizations Available NCP for all nurses countrywide Support from HHRDB and Nursing Advisers of the DOH Nurses movement from internal to external arena for migration or work abroad thus brain draining might occur Issues from the external stakeholders Climate changes and environmental issues Erratic change of DOH priorities due to change of Leadership Political and Social Issues Limited budgets and grants by DOH and DBM Figure 3.2- Example # 1 of SWOT Analysis Hospital Nursing Service Administration Manual 37

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The Administration of Nursing Services Strengths Weaknesses Opportunities Threats Analysis Advanced nursing practice (APN) becoming recognised as a valid part of nursing and health care service provision globally STRENGTH WEAKNESS e Determination (and stamina) to reach goals e Poor role clarification e Participation and formulation in policy e Uncertain identity e Highly skilled e Proliferation of titles e Able to work independently e Lack of clear identity affecting ability to e Capable of undertaking complex decision communicate clear messages making in relation to patient care e Lack of recognition by other health e Evidence of competence of nurses, and professionals managing complex health problems e Mistrust in nursing between and other nurses e Evidence of capability to deliver PHC and be with medical rather than nursing values entry point into the health system e Scope of practice conflicts with other health e Consumer trust professionals e Demonstrated acceptance by public e Failure to get into human resources planning e Information technology is used to access (needs assessment, role descriptions) information e Absence of career ladders e Affiliated/and or organised as a group| ¢ Fragmentation/ variability in standards and internationally and nationally in some quality of education programmes countries e Educational programmes may not keep up e When not organised have a willingness to with the changing realities of practice create some form of professional organisation | e Insufficient numbers of mentors e Show great commitment and will to act to e Inability to properly cost services (private advance practice provider) e Lack of a political will in supporting the role OPPORTUNITIES THREATS e Diversity of practice e Medicalisation of health systems —medical creating discussion/ stimulating interest dominance globally Territorial protection e Migration opening new opportunities to learn | e Insufficient influence to affect health and advance personal competence decisions and resource allocation Health care systems in crisis globally e Inadequate political skills/ strategies Nurses ability to influence health care e Diversity may lead to fragmentation through grass root means as well as by e Apathy influencing top policy makers e Burnout e Workforce development in flux Changing e Low status of nurses —poor payment, health care environment recognition and contributions health care not e Interest in innovative healthcare delivery valued models e Severe staff shortages e Sharing good practice e Lack of clinical career pathways e Increasingly aware and vocal consumers who | ¢ = Insufficient faculty want to be involved in health decision e Insufficient definition of roles and scope of making practice e Nurses can bring much experience and e Low levels of funding— for education and knowledge to health care and occupy a post creation pivotal position (deal with primary needs of human beings) 38 Hospital Nursing Service Administration Manual

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Planning the Nursing Service Nurses seen capable of taking a leading role in health/social development Nursing education moving into the university sector Rising demand for management of chronic disease Physician shortage Figure 3.3 — Example # 2 of SWOT Analysis . Pestel or Pestle Analysis It is a tool that is used to identify and analyze the key drivers of change in the strategic or business environment. The acronym stands for: Political, Economic, Social, Technological, Environmental and Legal Factors. The tool allows in the assessing of the current environment and potential changes. The idea is, if the project is better than competitors, it would be able to response to changes more effectively. Political. Every project has both internal and external politics. The internal politics like team jealousies, cohesive projects and personnel interests occur in all projects and must be considered and managed by stakeholders. The external politics refer to those which the stakeholders do not control. These events include all political events like employment laws, tax policies, trade restrictions, trade reforms, environmental regulations, political stability, tariffs. etc. Economic. This factor takes into consideration all events that affect the internal and external economic environment. Sociological. The sociological factors take into consideration all events that affect the market and community socially. Thus, the advantages and disadvantages to the people of the area in which the project is taking place also need to be considered. These events include cultural expectations, norms, population, dynamics, healthy consciousness, career attitudes, global warming. Technological. This factor takes into consideration all events that affect technology. Since technology often becomes outdated within a few months after it is launched. It also includes all barriers to entry in certain markets and changes to financial decisions. Environmental. This factor takes into consideration ecological and environmental aspects that could be either economic or social in nature. These include temperature, monsoons, natural calamities, access by rail, air and road, ground conditions, ground contamination, nearby water resources. Legal. This factor takes into consideration all legal aspects like employment, quotas, taxation, resources, imports and exports. Hospital Nursing Service Administration Manual BY:

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The Administration of Nursing Services POLITICAL ninic SOCAL ce Figure 3.4 Example of Pestel or Pestle Analysis C. STEEPLE Analysis This is a strategic planning tool which can be helpful when planning the strategic positioning which is more advance as it deals with macro-environmental external factors. S - Social e Income distribution e Demographic changes e Labour / Social Mobility e Lifestyle Changes e Fashion Changes T — Technological New invention and development Rate of technology transfer Life cycle and speed of technological obsolescence Change in mobile technology Change in information technology 40 Hospital Nursing Service Administration Manual

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Planning the Nursing Service E — Economic e Economic growth e Unemployment policy e Inflation, interest rates and other monetary policies e Consumer confidence E — Environmental / Ecological e Environmental regulation P — Political e Government organization / attitude e Political Stability / Instability L-Legal e Tax policies e Employment laws e Safety regulations e Competition regulations E — Ethical Values e Moral Values D. Balanced Scorecard The balanced scorecard (BSC) is a strategic planning and management system that organizations use to: Communicate what they are trying to accomplish. Align the day-to-day work that everyone is doing with strategy. Prioritize projects, products, and services. Measure and monitor progress towards strategic targets. Balanced Scorecard is a planning tool used in collecting and analyzing the data from four organizational perspectives: customer/stakeholder, internal process, learning and growth, and financial. This aims to develop objectives, measures or key performance indicators, targets or thresholds, and initiatives. The primary objective of creating and implementing a balanced scorecard is to increase efficiency and productivity. However, balanced scorecard approach offers many other benefits. This highly effective business strategy enables organizations to:

1. Identify or reassess “value drivers” who are key to achieving the mission of department and division.
2. Enable leadership to manage more effectively and respond to trends more quickly.
3. Focus attention on the few activities that will most affect results.
4. Improve departmental performance. Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Hospital Scorecard One of the identified strategic pillars of the FOURmula One Plus for Health (F1 Plus), the “Plus: Performance Accountability across all Pillars” aims to institute transparency and accountability measures at all levels. The publication of user- friendly scorecards and performance reports is one of the key interventions and requirement highlighted in this sub-pillar, as indicated in the AO 2018-0014. A user- friendly scorecard is a performance and reporting tool, which shall be integrated to improve management of the hospitals and their performances (See Appendix F, Hospital Scorecard). Cunical Quaury FINANCIAL VIABILITY Adverse Events (AEs) ‘Net Revenues ‘Clinical Outcomes ‘Volume ‘Mortality “Growth ‘Nosocomial Infections ‘Inventory Turnover Balanced oe Scorecard oe ‘Patient Experience “Accreditation Readiness Staff Loyalty “Staff Efficiency «Provider Satisfaction *Readmission Rate “Critical Care Capture Rate «Length of Stay (LOS) Customer LovaLry OPERATIONAL EFFECTIVENESS Source: B. Inozu, D. Chauncey, V. Kamataris, C. Mount: Performance Improvement for Healtheara: Leading Change with Lega, Six Sigma, and Constraints Management Copyright © McGraw-Hill Education, All rights reserved Figure 3.5 Framework of Balance Scorecard (sample) 42 Hospital Nursing Service Administration Manual

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Planning the Nursing Service Budgeting for the Nursing Service The Chief Nurse and the Nurse Managers shall have a budgetary plan and take responsibility in monitoring and control of all expenditures incurred. Budgeting for the Nursing Service is a detailed financial plan that estimates the revenues and expenditures for a period of time in order to deliver the patient services. It is a plan for allocation of resources based on preconceived needs for the proposed programs, projects, and activities of the nursing unit/department aligned with the organizational goals. The budget describes in details how the resources such as money, time and people will be acquired and used. Thus, itis imperative that every nurse manager in all management levels gain expertise in budget planning and processing. This is for purposes of effective and efficient utilization of resources that will translate to organizational financial sustainability. Purposes of Budgeting the Nursing Service e Control cost e Establish annual budget plan e Identify and analyze actual experience compared to the budget plan e Accurate utilization report Importance of Budget e It tells how much money the Nursing Service needs to carry out the activities. e It enables to monitor income and expenditures. e Itserves as a basis for financial accountability and transparency Generally, there are two kinds of budget:

1. Operating Budget accounts for the revenues and expenses associated with day to day activities within the nursing unit/ department / organization for the forthcoming fiscal year. The revenues are primarily from the patient care income based on the volume and mixed of patients, rates, discounts, and reimbursements from the third party payers. The expenses can be classified into: a. personnel services, which include employees’ salaries and benefits, b. maintenance and other operating expenses, which includes medical — surgical, drugs and office supplies, repairs and maintenance, learning and staff development needs and research activist. Hospital Nursing Service Administration Manual 43

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The Administration of Nursing Services 2. Capital budget reflects expenses related to the purchase of major capital items such as state of the art equipment and creation of new services that necessitates either construction or renovation of physical plant. Nurse Managers are asked to prepare a capital budget because most healthcare organizations are buying through consortiums or negotiated agreements with a particular supplier. Thus the role of the nurse managers are to assist the authorized body in the organization in selecting the best products based on set criteria and determining the amount of the equipment needed for their units/ department. Analysis of operations required in budget planning for the period covered, helps the Chief Nurse weigh the values and establish priorities in nursing programs. Budget Preparation The participation of the Chief Nurse in the budget preparation has the following advantages: Increased cost effectiveness through the analysis of activities and results of past experiences may lead to modification of future plans and objectives. Cost containment through the efficient use of resources. Cost consciousness. The Nursing Service budget is primarily concerned with: Maintenance and Other Operating Expenses (MOOE), e.g., supplies, training and research; Personnel Services (PS) e.g., salaries; Capital Outlay (CO) e.g., equipment (new, replacement, repair, maintenance and infrastructure; Training and Staff Development; and Researches Role of Nurse Manager The administrator requires sufficient funds to support sound program. The administrator submits a budget request and a justification for the proposed expenditures Budget is presented to the Medical Center Chief The budget is reviewed, analyzed and modified on the basis of discussions to the budget committee Once revisions are made, presents the budget to executive committee for approval When the budget is approved, it has given authorization to make expenditure and to collect income as indicated in the budget 44 Hospital Nursing Service Administration Manual

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Planning the Nursing Service e When the budget is adopted, administrator is committed to support the budget e Once the budget is approved, it is the responsibility of the administrator to see that expenditures do not exceed the approximates 1 made to the institution Budgeting Process The procedures below describe the process of how the Nursing Services under the Department of Health Hospitals do their budgeting. Budgeting process is defined as critical exercise of allocating revenues and borrowed funds to attain the economic and social goals of the country. It entails also the management of expenditures that will create the most economic impact from the delivery of goods and services while supporting a healthy fiscal position. The budgeting process involves four (4) distinct phases. Phase 1 - Gathering of Data e Analyze the overall past performance based on targets e Perform environmental scanning e Determine the overall nursing service department revenues and expenses based on the proposed budget plan of each nursing unit/section. Phase 2 - Planning e Form budget committee e Set objectives based on strategic goals e Determine projects & programs to achieve the goals e Develop budget guidelines in coordination with finance group e Determine operating and capital budgets e Conduct budget hearing and justify as needed e Allocate budget according to priority e Finalize the proposed master nursing service budget plan Phase 3 - Approval and Execution e Consolidate the proposed master nursing service department budget plan and submit to authorize office like finance department and or hospital budget committee for review and approval e Modify the proposed master budget plan as necessary like alignment to General Appropriations Act (GAA) and change in resources availabilities e Execute the budget plan accordingly by cascading to all nursing units/department Phase 4 - Monitoring and Reporting e Monitor the implementation of the budget plan e Perform variance analysis between the projected budget and actual performance e Interpret and justify the results as required to determine significant trends e Adjust and modify the budget plan as necessary based on needs e Submit financial report according to hospital policy 45 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Factors in Determining Budgetary Requirements e Review of pertinent provision in the current General Appropriation Act. e Identify sources of funds (General, national, city, municipal, provincial, special, revolving, trust.) e Review current appropriations and actual expenditures for the current year. e Study proposed changes in other departments which might affect the Nursing Service budget. e Estimate required expenditures for the coming year supplies, materials, equipment, repairs, and replacement. e Estimate personnel salaries and benefits, as well as savings derived for unusual leaves. e Estimate cost of Human Resource Development and Research Programs. e Translate this information into peso and submit the official forms to the Medical Center Chief for approval and inclusion in the general budget. Developing a Budget Plan for the Area of Responsibility Each supervising nurse/ senior nurse develops a budget for his/her own area of responsibility every quarter of the ensuing year with the first quarter broken down into months. Example: Allotment for the 1 quarter — Php 24,000 e 1*month

Php 8,000 e 2TMmonth

Php 8,000 e 3%month

Php 8,000 The plan should include the number and kind of personnel, their salaries, fringe benefits, the number of patients to be served, the activities within an area, and the kind of care the patients are supposed to receive. Operating Expenses shall include among other things, the number and kind of supplies, repairs, maintenance, books and in-service education and training. Analyzing and Controlling the Prepared Budget A reporting system is devised such that monthly reports show how much has been spent on what and whether it exceeded the budget or not. Over expenditure must be controlled. 46 Hospital Nursing Service Administration Manual

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Planning the Nursing Service Review the Budget Plan Review the plan for maximum efficiency and cost saving or corrective actions. Budget for the Fiscal year should include: e Personnel — salaries, wages, benefits, insurance, premiums, retirement, allowances, and consultancy (Honorarium); e Operations — such as drugs, medical and surgical supplies, and equipment according to the need of patients confined and treated e Training/ Research — supplies, equipment, honoraria and official travels e Allocation of Resources Project Planning Project planning is the process applied to specific proposal or program. It is a discipline for stating how to complete a project within a certain timeframe, usually with defined stages, and with designated resources. One view of project planning divides the activity into: e Setting objectives (these should be measurable) e Identifying deliverables e Planning the schedule e Making contingency plan Phases of Project Planning Phases Activities Phase 1 e Clearly state the purpose or mission of the project. e Assess the situation. Developing a Plan o Determine the kind of information needed. This information serves to:

validate the identified problem;

point out the factors affecting the problem; and

• — yield an estimate of the expected responses to the change. o Based on the information gathered, analyze the problem. Find its source (internal or external) e Formulate the objectives e Propose alternative courses of action e Choose a particular course of action. Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Phases Activities Phase 2 Obtain the approval of the concerned authority/agency for the presentation of the plan. Presenting the Plan Prepare for the presentation. Give special attention to the following: o Manner of delivery/ presentation, should be:

persuasive

concise

professional

personalized

imaginative Phase 3 Plan for implementing and monitoring Implementing and o Activating the method of delivery. Monitoring the Plan o Monitoring the time frame, target population, expected outcomes and cost factors. o Evaluating the outcome of the plan. o Updating the plan and revise as necessary 48 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service 4 ORGANIZING THE NURSING SERVICE At the end of this chapter the Chief Nurse and Nurse Managers shall be able to: Discuss organizing as a management function Select activities that can demonstrate sufficient expertise Design an evaluation tool for recruitment and selection of staff Discuss skills and competency gaps more efficiently Develop customized learning and development intervention for professional growth Utilize change management process more efficiently Once plans are made, the mission, purpose for which the organization exists has been established, the philosophy developed and adopted, and the objectives formulated - resources are organized to sustain the philosophy and to accomplish the mission and objectives. Organizing is the process of identifying and grouping the work to be performed, defining and delegating responsibility and authority and establishing relationships for the purpose of enabling people to work most effectively together in accomplishing the objectives (Lows A. Allen, 2011). It follows planning as a second phase of the management process. Purposes of Organizing 1. 2. 3. 4. 5. Formulate a team so that they may work together to achieve objectives Assign activities with an authority that can supervise the team Design a formal system so that roles are clear, everyone knows who is to do, what and who is responsible for what results Establish a positive work environment for the staff to effectively accomplish their goals Collaborate and coordinate productively within and outside their department Steps in Organizing fa FS, G2 BO ie Consider the plans and goals of the organization Determine the work activities necessary to accomplish objectives Classify and group activities that are interrelated Assign work and delegate appropriate authority Design a hierarchy of relationships both horizontal and vertical 49 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Organizing Principles The basic organizational principles below should be considered in designing the nursing department’s table of organization and educating the nursing personnel to function effectively in the structure. The Principle of Chain of Command. Organizations are established with hierarchical relationships, with authority that flows from top to bottom. This supports a centralized authority that aligns authority and responsibility. Communication flows through the chain of command that tends to one way- downward. In modern nursing organization, the chain of command is flat. Communication flows freely in all directions, with authority and responsibility delegated to the lowest operational level. The Principle of Unity of Command. An employee has one supervisor. There is one leader and one plan for a group of activities with the same objective. However, this is modified by an emerging organizational theory where nurses and others are frequently engaged in matrix organizations in which they answer for more than one supervisor. The Principle of Requisite Authority. When responsibility for a particular task is delegated to a subordinate, the latter must also be given authority over resources needed for task accomplishment. He/she is accountable for the quality of his/her work. The Principle of Span of Control. This states that a person should be a supervisor of a group that he/she can effectively manage in terms of numbers, functions, and location. In the past, the managers had a limited span of control, with few staff. Recently, the span of control has increased to cover more nursing units and departments with large numbers of employees. The Principle of Specialization. Each person should perform a single leading function. Thus, there is a division of tasks and responsibilities based on the specialty of the individual or groups. The Principle of Continuing Responsibility. When a manager delegates a function to a subordinate, the manager’s responsibility for that function is in no way diminished. The Principle of Organizational Centrality. Nursing personnel interact with the greatest number of other healthcare workers, receive the greatest amount of work-related information and become most powerful in organizational structure. The Exception Principle. Subordinates should report only unusual from normal functioning, so that managers can limit their attention to events that are unresponsive to routine control mechanisms. The Principle of Esprit d’ Corps. \t means teamwork and implies that in unity there is strength. 50 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service Nursing Service as an Organization The Nursing Service is one of the largest divisions of a Department of Health hospital. It is headed by a Chief Nurse (Nurse VII, Nurse V1, Nurse V, Nurse IV and Nurse III depends on the classification and level of the institution) The Chief Nurse is directly responsible to the Director of the Hospital or the Medical Center Chief. The Chief Nurse is assisted by the Assistant Chief Nurses, (Nurse VI), Department Managers, Ward Supervisors (Nurse III), and (Nurse II), and the Staff Nurses (Nurse I) that provide direct patient care. The Nursing Service is tasked with the responsibility to provide safe quality care to patients thru standards of care and innovative programs that cater to the needs of the patient it serves. As an organization, it should have clear lines of authority and responsibility that should be clear to each employee. They should know their tasks, what is expected from them and their limitations. Roles and relationships with each other are clearly defined, so as there is no overlapping of functions and helps determine proper point for decisions. For the nursing unit, it should involve the type of work that provides direct patient care, the types of nursing personnel needed to perform this task and the span of supervision needed. The Organizational Structure of the Nursing Service The organizational structure furnishes the formal framework in which the management process takes place. It should provide an effective work system, a network of communications, and identity to individuals and the organization and should consequently foster job satisfaction (Tomey, 2006). Types of Organizational Structures e Formal Structure This structure shows the relationships among employees and their job positions. It describes the tasks, responsibilities and relationships. This can be presented in a diagram called the organizational chart. e Informal Structure This is based on social and personal relationships rather than on positional authority. It helps members achieve their personal and social needs. Good example of this structure in the hospital are the groups that belong to the same shift of the same unit where they work or those that meet during lunch or break hours to eat together. The informal structure has its own channel of communication, which can allow information to be disseminated rapidly more than the formal system. This called the “grapevine” and often seen in all organizations. This may Hospital Nursing Service Administration Manual j1

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The Administration of Nursing Services contain rumors that are not true and may create confusions or even conflict. The best way to correct these rumors is for the managers to provide accurate information through meetings, Bulletin Board posting or written memos. Every manager must be aware of its existence and try to use the grapevine to meet the organizational objectives. Forms of Organizational Structure

1. Hierarchical (tall, centralized, bureaucratic) This is commonly called line structure. It is a formal structure where authority and responsibility are clearly defined leading to simplicity of relationships. It is associated with the principles of command, vertical control and coordination levels, and downward communications.
2. Decentralized (flat, horizontal, participatory) The authority is shifted downwards to its divisions, services, and units. The decision-making can occur where the work is being carried out, thereby professionals who do the job can participate in managing the organization. This is the primary characteristic of this structure.
3. Matrix This is designed to focus on both the product and function. Function is the task required to produce a product that is the end result of the function. The manager of a unit responsible for a service reports both to a functional and product manager. Personnel assigned to a specific project may become responsible to two bosses — the product manager and the functional department head.

Hybrid A term applied to organizational structures that operate with characteristics of different types of structures. Characteristics of an Organizational Structure An organizational structure has five (5) characteristics: Division of Work: Each box represents an individual or sub-unit responsible for a given task of the organization’s work load, i.e., Hospital Operations and Patient Support Services, Medical Services, Nursing Services, and Finance Services. Chain of Command: It is reflected in the organizational structure with a solid line, or known as a line of authority. It indicates who reports to whom - the chain that can be flat (in decentralized organizations) or tall (in centralized organizations) Type of Work to be Performed: \t is indicated by label or description for the boxes like for examples: Patient Care Services, Ancillary Services, Training and Education Department, and Research and Quality Improvement Department. The Groupings of Work Segments or Homogenous Assignments: These are shown by clusters of work groups like for examples: Operating Room and Post Anesthesia Care Unit, Labor Room and Delivery Room Unit, Intensive Care and Coronary Care Unit, and Medical and Surgical Unit. Ey Hospital Nursing Service Administration Manual

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Organizing the Nursing Service e The Levels of Management: This indicates the individual and entire management hierarchy regardless of where the individual appears on the organizational chart. Hierarchy refers to a body of persons or things organized or classified in a pyramidal fashion according to rank, capacity of authority assigned to vertical levels with officers ranked in grades, orders or classes, one above the other. Examples: Top management, Middle management, Front-line management. Organizational Chart and its Implication An organizational chart is a line drawing composed of boxes that show how the parts of an organization are linked. It depicts formal organizational relationships, areas of responsibility, persons to whom one is accountable for and channels of communication (Tomey, 2004). There are two (2) lines in the organizational chart. e Unbroken Solid Lines The unbroken solid lines are classified into two. The solid horizontal lines represent communication between people with similar spheres of responsibility and power but different functions. The solid vertical lines between positions denote the official chain of command and formal path of communication and authority. Those having the greater decision —making authority are at the top; those with the least are at the bottom. e Dotted or Broken Lines This represents staff position. A staff member provides information and assistance to the manager but has limited organizational authority. It also provides for specialization but does not have legitimate authority as it acts in an advisory capacity. Relationships Within Nursing Service The relationships within the Nursing Services can be depicted through the organizational chart. These are known as: e Line Relationship - those that exist between the superior and subordinates who are immediately and directly responsible to him/her. Examples: Chief Nurse to Supervising Nurse, to Head Nurse to all nursing personnel. e Lateral Relationship - those that exist between positions in various divisions and sections of an undertaking where no direct authority is involved. Examples: Senior Nurse with Physician, Staff Nurse and Clinical Pharmacist. e Functional Relationship -those that arise when duties are divided on a functional basis like when an individual exercises authority on a particular subject by special skill or knowledge. Examples: Chief Nurse with Administrative Officer, Staff Nurse with Clinical Nurse Instructor. e Staff Relationship - is when the individual is not vested with, but is acting “for and in behalf’ of the person on which the authority lies. The individual Hospital Nursing Service Administration Manual 53

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The Administration of Nursing Services function is one of transmission and interpretation coupled with the duty of ascertaining that the orders given are carried out. Kinds of Organizational Chart Basically, there are three (3) kinds of organizational charts. These are: e Structural Chart shows the various components of the organization and outlines the basic interrelationships. e Functional Chart reflects the functions and duties of the components of the organization and indicates the interrelationships of these functions. Within the boxes is the function statement, which should be clear, inclusive and written in the present tense. e Position Chart specifies the names, positions and titles or ranks of the personnel, which fit into the organizational structure. It identifies channels of communication, levels of accountability and areas of responsibility. Organizational Chart Level 3 Hospital 200, 300, 400 500 Bed Capacity Basic Organizational Structure Office of the Medical Center Chief Integrated Hospital Operations and Professional Education Management Program and Training (IHOMP Unit) i | Medical Nursing Non-Medical Medical Service Nursing Service Hospital Operations ang Finance Service Patient Support Service 4 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service Nursing Service Office of the Medical Center Chief Nursing Service Clinical Nursing Units Operating Room Special Care Areas Obstetric Complex Pulmonary / Respiratory Unit Labor Room Delivery Room Obstetrical OR Recovery Room Central Supply & Sterilization Hospital Nursing Service Administration Manual 35

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The Administration of Nursing Services Office of the Medical Center Chief Integrated Hospital Operations & Management Program (HOMP) Unit | Legal Affairs em | Professional Education and Training

oe | Hedical | Nursing |[Non-siedicat | Continuous Quality Improvement (CQ) | Hedicine | Out-Patient | | Ancitiary | [_auled Heath Surgery

SDSHME Medicine Dept. of Laboratory | | Health Cashiering Operating htomation Pati CE ese Room a [_Biood sank _| | | Management Dumineas jatri — OB-Gynecolo Rodiathies Delivery Room 2 ay Dept. of Radiology i Hanegemom ‘ali | Pediatrics Social Work 5 onic ann

Emergency Dental BilingiClaims Room rj Anesthesia saan abtiad Nutrition and

abilitation oteti Special

|_| out-Patient Dietetics Services Department Central Supply fmm Public Heatth & Sterilization [7] unit Operating Room Room Specialized Care Areas Figure 4.2 Organizational Chart J Housekeeping Hospital Nursing Service Administration Manual H 56

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Organizing the Nursing Service Medical Center Chief Nurse “ -------4 Colle » ie Nrlng NurseVI 9 |-------4 Nurse V1 L— Ff “chal ch ordinator Nurse] 8 9 |-------4 Nurse] 2 22 = |-~----—4 Clinical Instructor Nurse II Nurse I Students Direct line of authority and responsibility Figure 4.2 Organizational Structure Showing Relationships of the Nursing Service with the College of Nursing Hospital Nursing Service Administration Manual 57

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The Administration of Nursing Services Medical Center Chief Chief Nurse Dean, Colle ge of Nursing | Clinical Coordinator Asst. Chief Nurse Asst. Chief Nurse (Clinical) (Bhucation, Training & Research) Nurse IV Nurse IV OR OB Nurse III Nurse III Midwife Nurse Il Nurse II Nurse I Nursing Attendant II Nursing Attendant II Nursing Attendant I Nursing Attendant 1 Figure 4.3 Functional Structure of the Nursing Service Showing Levels of Position 58 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service Limitations of Organizational Chart There are limitations of an organizational chart. These are as follows, but not limited to: 1. 2 4. The organizational chart does not show the informal structure of the organization. It is limited in its ability to depict each line position’s degree of authority. The organizational chart becomes obsolete very quickly. It may depict how things should be but in reality, the organization still functions under the old structure. It may define authority, but not responsibility and accountability. Organizational Effectiveness Organizational Effectiveness (OE) is doing the right things towards realization of organizational goals through highly motivated and empowered human capital, efficient and judicious use of resources and resulting to enhanced customer services and satisfaction. This is directly related to organizational performance (OP). Many nurse managers look at OE with the following goals: Patient and family satisfaction with care Staff satisfaction with work; rewards; professional development that includes career, personal and educational, and the whole organization Management satisfaction with staff Organizational health Community relationships Characteristics of Organizational Effectiveness Organizational effectiveness is characterized by the following criteria: Is There is Strong Transformational Leadership. The leadership approach causes changes in the individual and the social system. The leader challenges the staff to greater ownership of work and understanding their weaknesses and strengths to optimize performance. The leader enhances motivation and performance of followers by modeling the way to performance. There is High Employee Morale. The employees are highly motivated, valuing their positions and the organization. They commit to work for a long time, thus productivity is high and goals and objectives are achieved. There are Shared Goals, Which are Already Cascaded. The management shares goals with employees and gets them on board with the mission and vision, goals and values of the organization. Learning and Development of Staff are Maximized. The organization provides means and measures to enhance knowledge, skills, and attitude through various certifications, continuing education and other learning opportunities. Hospital Nursing Service Administration Manual 59

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The Administration of Nursing Services 5. The Organization Builds a Culture of Research and Evidence-Based Clinical Nursing Practice. Research and evidence-based nursing practice are clearly seen in the goals, objectives, and activities of the nursing service. These are effectively communicated to all employees. Significant resources are properly allocated for staff training and support. 6. The Organization Promotes Teamwork and Collaboration. The nursing personnel work as a team or belong to committees of the hospital. They are able to communicate openly and share positive and constructive criticisms. Each team member values and respects each other. They also interact socially. 7. There is a Well-Defined Organizational Structure. The organization is formal and possesses a sense of order as seen their structure. 8. The Systems and Processes are Institutionalized. The systems and procedures are embedded in the organization, which enhances stability. The employees are guided by a set of rules or procedures that are acceptable, dependable, and valid. 9. The Organization Manages the Risks. Healthcare managers identify and evaluate risks as a means to reduce injury to patients, staff, and visitors. The managers work proactively and reactively to either prevent or minimize damage following an event. Organizational Culture Organizational culture is a system of symbols of interactions unique to each organization according to Marquiz (2009). It is the ways of thinking, behaving, and believing that members of a unit have in common. Waters (2004) defines it further as “the source of motivated and coordinated activities within the organizations, activities that serve as foundation for practices, and behaviors that endure because they’re meaningful, have a history of working well and are likely to continue working in the future.” It is the management function to build a constructive culture in the workplace. This requires the interpersonal and communication skills of a leader. It is important to support a “nurse-friendly” culture where nurses can function effectively and efficiently. The leader must take an active role to ensure this. According to Kance-Urrabazo (2006), there are four (4) critical components that a leader-manager can influence. These are trust and trustworthiness, empowerment, consistency, and mentorship. The leader-manager has an important and significant role in shaping the organizational culture for their staff. The person should choose strategies that encourage a shared culture through orientation, meetings, storytelling, and performance review. 60 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service Teamwork Today’s healthcare industry is built around a multidisciplinary approach to patient care. Nurses work closely alongside physicians and specialists to provide well- organized comprehensive care; therefore, teamwork is crucial to facilitating effective communication and promoting positive patient outcomes. Teamwork in health is defined as two or more people who interact interdependently with a common purpose, working toward measurable goals that benefit from leadership that maintains stability while encouraging honest discussion and problem solving. Benefits of Teamwork in Nursing e Improved satisfaction and outcome e Higher job satisfaction e Increased professional accountability e Lower rates of turn over e Improved engagement in the workplace Five (5) Ways to Foster Teamwork

1. Start the Wave. Be the first to help another nurse with a difficult patient. Assist with activities of daily living, bathe the patient, or do whatever your colleague needs to stay on schedule. You'll soon find her returning the favor.
2. Be a Mentor. Take new nurses under your wing and help them feel at home in your department. Offer to be a resource if their preceptor is unavailable. By demonstrating to them that you're a team player, you'll encourage them to follow suit.
3. Ask for Help When You Need It. If you find yourself falling behind in your schedule, ask a colleague for assistance. That way, you won't become frustrated when you think of all the other things still left on your to-do list.

Think Ahead. Have as much preparation ready for the next shift as possible. For example, place another bag of intravenous solution in your patient's room if the current bag is almost empty, or leave a spare set of sheets in your patient's room for middle-of-the-night bed changes. 5. Be Prompt for a Report. Unless you're in the middle of an emergency, give report when the next shift is ready for it. Nothing is more frustrating than starting a shift behind schedule. Finish what you were doing when you're done with the report. Teamwork in healthcare is significant. It employs the practices of collaboration and increased communication to expand the roles of nurses and to make decisions as a unit or division that works towards a common goal that of delivering healthcare to clients. Working as a team has been established to reduce errors and increase patient safety. Research studies have also established that teamwork reduces burnout and that successful team effort produces more satisfaction at work. Hospital Nursing Service Administration Manual 61

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The Administration of Nursing Services Team Building Team Building is the process of gathering the right people and getting them to work together for the benefit of a project. Having the right core team can make or break a project. Therefore, great care should be taken when selecting team members. The team could include: e People who understand the project very well e People who are technical experts
e People who can provide objectivity in the process and outcome Factors to Consider in Selecting Team Members e Committed to the common purpose and goals Enthusiastic Optimistic Creative, flexible and open minded Proactive Cooperative Respectful of the values, beliefs and opinions of others Team Building Process Hereunder are the two (2) phases of team building process and activities: e Phase l o Conduct self-awareness enhancement seminar o Conduct leadership and management seminar o Work with participants to develop the skills required for them to lead their teams effectively, whether they are currently fulfilling a leadership role, or have the potential to do so o Work cooperatively with the participants so they recognize the skills and attributes that are important in a leadership position and through this process, also learn to recognize their own strengths and opportunities for improvement e Phase 2 o Develop appropriate leadership styles, tools and strategies for specific health care facilities Analyze team strengths and weaknesses Structure a plan of action Set team goals using a team approach Help members understand the role of the individual team membership Show team how to meet the needs of the overall group Develop the skills needed to implement the action plan ooo0o000 62 Hospital Nursing Service Administration Manual

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Organizing the Nursing Service Each organization has a team, which is used mainly at the operating level. It is composed of a group of people with different backgrounds, knowledge, and skills, who work together for a purpose or defined task. This is usually small in number and has a team leader. The role of a team leader enhances: (a) communication, (b) mindset and attitude, (c) creative problem-solving, (d) delegation, (e) management of team members emphasizing the effect of the part on the whole, and (f) crisis management. Team building trainings are ideal for any growing team. This is for team leaders who need to refresh and update their skills and for team members who require a better understanding of their importance and function within their team and its value to the organization. Nursing Service Committees Committees are groups that evolve out of the formal organizational structure. This is one way to let the staff get involved in the organization. Committees provide a voice in the management. It can facilitate communication, promote loyalty, reduce resistance to change, gather people with special skills needed in the task, and allow nursing personnel the chance to work together. The committee should have a purpose, objectives, and operational procedures. It should have an effective chair that has the skills of group dynamics. Each committee is established by an appropriate authority, administrative order, hospital/department memo, and others. There should also be recorded minutes of the meetings for proper documentation. Purposes 1. Inform staff member of standing committees 2. Improve committees input by identifying committee membership for all Nursing Service Personnel and the assigned job to do 3. Take responsibility for specific on-going work in the nursing service Scopes 1. The nature and composition of the group along with its duties and responsibilities must be clearly defined. 2. The committee is an advisory body to the nursing administrator in the hospital Types of Committees There are two (2) types of committees: I. Ad Hoc or Task Force This is a group of individuals who work together on a specific project that is time framed. Examples are: A group who will investigate a case on increasing Hospital Nursing Service Administration Manual

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The Administration of Nursing Services 2 medication error in the nursing unit or a group responsible for the nursing activities related to the Foundation Day of the Hospital. Examples are: Ethics Committee Research/Evaluation Committee Nursing Audit Committee Grievance Committee Standing Committee This is a group that has advisory function. The group recommends measures to improve services. It also implements actions directed to committee functions. Examples are: Infection Prevention Control Committee Patient Safety Committee Continuous Quality Improvement Committee Responsibilities of Each Committee The following are the ongoing responsibilities of the Nurses Committee. To foster regular communication between nurses To share and promote evidence-based findings and practice through knowledge translation, standardization and systematic evaluation in clinical practice settings. To be actively involved in the planning and execution of nurse’s programs and meetings To disseminate information on guidelines, research projects, and educational materials relevant to nurses and/or their patients Provide mentorship to nurses in their role to teach, coach, individualize, and intervene in applying evidence-based practice Support systematic evaluation and dissemination of practical and actionable standardized or targeted interventions for this unique patient population that is provided by nurses. Submit written reports to nursing service every month 64 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service 5 STAFFING IN THE NURSING SERVICE At the end of this chapter the Chief Nurse and Nurse Managers shall be able to: e Discuss staffing as a management function e Complete the staffing needed at a given area in a given time e Formulate a manpower plan Staffing is the most crucial, complex, and time-consuming management function of a nurse manager at every level of the healthcare organization because the quality of the Nursing personnel and their performance will determine the degree by which the goals of the Nursing Service are achieved. Although the goal of Nursing is focused primarily on providing a competent Nursing workforce to achieve the best patient clinical outcomes at reasonable cost, the healthcare environment has been becoming increasingly complex. Rowland (2004) defined staffing as the “process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patient’s demand for care.” Safety of the patient shall be the fundamental principle to guide staffing. It is also mostly relevant in the compliance of minimum requirements for the hospital licensure to ensure quality and safe delivery of care to patients. Importance of Staffing e Recruits competent personnel for various clinical areas based on patient’s needs. e Allocates job tasks properly among the nursing personnel according to their qualifications, and specializations. e Provides the numbers and mix of nursing staff needed per nursing unit. e Ensures adequate and equitable manpower for efficient and effective delivery of nursing care. e Optimizes the utilization of nursing human resource at the least manpower cost but high on quality nursing care. e Retains, develops, and places the right nursing staff in the right job positions. e Improves productivity through role clarity, effective communication, and teamwork. Hospital Nursing Service Administration Manual 65

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The Administration of Nursing Services Principles of Staffing The principles of staffing are adapted from the American Nurses Association as cited by Yoder-Wise (2011).

1. Patient Care Unit Related Appropriate staffing levels for a patient care unit must reflect analysis of individual and aggregate patient needs. There is a critical need to either retire or seriously question the usefulness of the concept of nursing hours per patient day. Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels.
2. Staff Related e The specific needs of various patients’ population should determine the appropriate clinical competencies required of the nurse practicing in that area. Registered nurses must have nursing management support and representation at both the operational level and the executive level. Clinical support from experienced registered nurses should be readily available to those registered nurses with less proficiency.
3. Institution/Organization Related Organizational policy should reflect an organizational climate that values registered nurses and other employees are strategic assets and exhibit a true commitment to filling budgeted positions in a timely manner. All institutions should have documented competencies for nursing staff including agency or supplemental traveling registered nurse for those activities that they have been authorized to perform. Organizational policies should recognize the myriad needs of both patient and nursing staff. Factors Affecting Staffing There are factors affecting staffing that should be considered in determining the number and mix of nursing personnel. These are as follows but not limited to: Patient factors

census fluctuations patient acuity level of care /degree of dependence patient age group special treatment and procedure communicability rehabilitation needs patient and family care demands/expectations 66 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service 2. Staff factors number of nursing staff available ratio of professional to non-professional number of leaves turn-over rate absenteeism rate proficiency level span of supervision 3. Nursing Service factors e nursing care modality in use e type of services/patient classification system e patterns of work schedule e e training and staff development programs research activities 4. Healthcare organization factors e type of hospital services offered/population served work time policy administrative policy on weekend and holiday duty presence of support services nursing unit architectural design availability of resources like equipment, materials and supplies technology anticipated e projected units of services e budget limitations ° Patient Care Classification System The Patient Care Classification System is primarily developed to objectively determine workload requirements and staffing needs. It is a means of categorizing patients on the basis of certain needs that can be clinically observed by the nurse. It aims to respond to the constant variation in the care needs of patients. It is essential to staffing the nursing unit of hospitals for it quantifies the quality of nursing care. The patient then can be assigned to an acuity or complexity category that will indicate how many actual hours of nursing care the patient needs during a particular shift. The Nursing Care Hours Per Patient Day (NCHPPD) is defined as a standard measure that quantifies the nursing time available to each patient by available staff. It simply means the amount of time nurses spend with each patient per day. It is calculated by dividing the total number of productive hours worked by nurses with direct patient care responsibilities with the total census or number of patients in a day or month or year. Hospital Nursing Service Administration Manual 67

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The Administration of Nursing Services The formula is: NCHPPD = Total of hours worked in 24 hours Total patient census in a day Example: 12 total nurses working 8 hours each in 3 shifts 12x8= 96 worked hours. = 2.4 NCHPPD 40 patients The various nursing units may develop their own ways of classifying patient care according to the acuity of their patient’s illness. The figures below are examples of patient care classifications with nursing care hours/patient/day and ratio of professionals (clinical nurses) and non-professionals (assistive nursing personnel): Table 5.1 Classification of Patient Care by Units, Nursing Care Hours/Patient/Day and Ratio of Registered Nurses to Non-Professional Staff Needed Patient Care Units Nursing Care Ratio of Nurses to Hours/Patient/Day Non-Professional Staff General Medicine 3.5 60:40 Medical 3.4 60:40 Surgical 3.4 60:40 Obstetrics 3.0 60:40 | Pediatrics 4.6 : 70: 30 PICU/NICU 6.0 70: 30 ER/SICU/PACU 6.0 70: 30 MICU / CCU 6.0 80: 20 68 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service Table 5.2 Classification of Patients by Levels of Care, Nursing Care Hours/ Patient/Day and Ratio of Professionals to Non-professionals Needed Levels of Care Nursing Care Ratio of Nurses Hours/Patient/Day to Assistive Personnel Level 1 Self-Care or 1.5 55:45 Minimal Care Level 11 Moderate Care or Intermediate Care od i Level 11] Total Care or 6.0 65:35 Intensive Care Level 1V Highly Specialized or 7.0 70:30 Critical Care or higher or 80:20 Level I — Self Care or Minimal Care. Under this category, the patient is capable of carrying out daily activities as long as the nurse provides the necessary materials and supplies. A patient who enters the hospital for diagnostic work-up that includes numerous laboratory, x—ray and other non- invasive tests, is often self-care patient for the duration of his work-up. Example, the average amount of nursing care hours per patient per day is 1.50 while the ratio of professional to non-professional nursing personnel is 55:45. Level II — Moderate Care or Intermediate Care. Under this category, the patient can feed, bathe, toilet and dress himself without help, but requires some assistance from the nursing staff for special treatment or certain aspects of personal care i.e. A partial care patient might require wound debridement or dressing, catheterization, colostomy irrigation, intravenous fluid therapy, intramuscular or subcutaneous injection or chest physiotherapy. Example, the average nursing care hours per patient per day is 3.0 and the ratio of professional to non — professional personnel is 60:40. Level III — Total, Complete or Intensive Care. Under this category, a bedridden patient who lacks the strength or mobility, needs nursing assistance for all of the patient’s daily activities, such as feeding, bathing, dressing, moving, positioning, eliminating, comfort seeking, and injury avoidance. Example, the average nursing care hours per patient per day is 6.0 with a professional to non-professional ratio of 65:35. Level IV — Highly Specialized Critical Care. Under this category, an acute or critically ill patient who is in constant danger of death or serious injury would require critical care. Patients need continuous assessment and treatment because of many IV medications on titration, vital signs every 15-30 minutes and hourly output Hospital Nursing Service Administration Manual 69

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The Administration of Nursing Services measurements. Frequently, there are also significant changes in doctor’s orders that need to carry out. Example, the average nursing care hours per patient per day is 7.0 or more, and the ratio of professional to non-professional ranges from 70:30 to 80:20. Moreover, the percentage of nursing hours to be given by professional nurses and by non-professional nursing personnel may depend on the patient’s condition in the hospital setting in which the care is being given. The table below is an example of patient classification according to type of hospital. Table 5.3 Classification of Patients by Levels of Care according to Type of Hospital with Percentage of Patients at Various Levels of Care Levels of Care Type of Hospital Minimal Moderate Intensive Highly Care Care Care Specialized Care Primary 70 25 5

Secondary 65 30 5

Tertiary 30 45 15 10 Special Tertiary 10 25 25 20 The table shows that for primary (Level 1) hospitals, it is assumed that about 70 percent of their patients need minimal care, 25 percent needs moderate care. Patients needing intensive care are given emergency treatment and when their condition becomes stable or when immediate treatment is necessary and the hospital has no facilities for this, the patient is transferred to a secondary (Level 2) or tertiary (Level 3) hospital. In (Level 2) hospitals, it is assumed that 65 percent of the patients need minimal care, 30 percent needs moderate care, and 5 percent needs intensive care. In (Level 3) hospitals, 30 percent of the patients need minimal care, 45 percent needs moderate care, 15 percent needs intensive care, and 10 percent needs highly specialized care. For special tertiary hospitals, it is assumed that 10 percent of the patients need minimal care, 25 percent needs moderate care, 45 percent needs intensive care, and 20 percent needs highly specialized care. 70 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service Staffing Methods Basically there are three methods of staffing to determine the number of personnel needed. These are: e Ratio-Based Staffing reflects the number of nurses assigned to care for a certain number of patients as a state-mandated regulatory requirement for a nurse-to-patient assignment. The figures below are the Department of Health- mandated nursing staffing ratios for government hospitals (Revised Organizational Structure and Staffing Standards for Government Hospitals, CY 2013 Edition). Table 5.4 Nursing Staffing Standards for Government Hospitals Unit Staff Distribution Ward 1 Ward Supervisor (Nurse III) : 50 staff nurses 1 Senior Nurse (Nurse II) _: 15 staff nurses 1 Staff Nurse (Nurse I) _: 12 beds / patients / shift 1 Nursing Attendant : 24 beds / shift Unit Nurse to Staff Ratio Critical 1 Ward Supervisor (Nurse III) : 30 staff nurses Care 1 Senior Nurse (Nurse II) _: 15 staff nurses | 1 Nursing Attendant: 15 beds / shift Acuity-Based Staffing reflects the severity of the physical and psychological status or illness of the patient. The intensity attribute of acuity indicates the nursing care needs and the corresponding workload required. Moreover, the nursing intensity is the number of nursing hours with associated costs and total time and staff mix of nursing personnel consumed by an individual patient during the episode of care. Table 5.2 is an example of acuity-based staffing method. Budget-Based Staffing means that nurses are allocated according to nursing care hours/patient/day. Tables 5.1 and 5.3 are examples of budget-based staffing method. WISN-The Workload Indicators of Staffing Need (WISN) method is a human resource management tool. It provides health managers a systematic way to make staffing decisions in order to manage their valuable human resources well. The WISN method is based on a health worker’s workload, with activity (time) standards applied for each workload component. The method: Hospital Nursing Service Administration Manual 71

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The Administration of Nursing Services e Determines how many health workers of a particular type are required to cope with the workload of a given health facility; e Assesses the workload pressure of the health workers in that facility. This is a revision of an earlier WISN user’s manual, which WHO published in 1998. This revised manual takes into account the now-decentralized nature of health management in many countries. It is thus intended for the wider range of managers working at the different levels in today’s health systems. WISN Help Human Resource Managers WISN is an analytical planning tool to: (See Appendix G, Sample WISN Analysis as Baseline for Decision-Making). e Determine how many health workers are required to cope with actual workload in a given facility e Estimate staffing required to deliver expected services of a facility based on workload e Compare staffing between health facilities and administrative areas e Applicable to all personnel categories

Medical Staff

Paramedical Staff

Non-medical Staff Calculating for the Number of Nursing Personnel Needed In calculating for the number of nursing personnel needed aside from the factors identified earlier the following provisions would be the basis of the computation: a. The number of working hours and off-duties in the country is largely dependent on a Forty-Hour-Per-Week Law otherwise known as RA 5901. This law specifies that personnel working in agencies with a population of one million and in hospital with a one (100) hundred bed capacity and over are entitled to work forty hours per week. On the other hand, nursing personnel who worked in agencies with a population of less than one million will have to render a forty-eight working hours a week, therefore getting only one day off a week. . The granting of three days special privilege to government employees by the Civil Service Commission as per Memorandum Circular No. 6, series of 1996, may be spent for birthdays, weddings, anniversaries, funerals (mourning), relocation, enrollment or graduation leave, hospitalization and accident leaves. Hospitals’ data revealed that although an employee is entitled to 15 days sick leave, 15 days’ vacation leave, 12 holidays, 3 days for continuing education, 72 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service and 3 days of special privileges or a total of 48 days, each nursing personnel gets only an average of 33 days per year. It is important to note that the average number of leaves (33 days/year) is used in the calculation of the number of relievers. Example, to determine the relievers needed, divide 33 (the average number of days an employee is on leave per year) by the number of working days per year that each employee serves (213 days for those working 40 hours/week or 265 days for those working 48 hours/week. Refer to figure 5.5). There will be 0.15 additional staff needed per personnel for those who work 40 hours per week and 0.12 per person for those working 48 hours per week. d. Research studies showed that the morning shift needs the most number of nursing personnel (45%) the afternoon shift needs about 37% and the night shift only about 18%. This is because more nursing care are given during the morning and afternoon shifts than those during the night shift. The table below summarizes the total number of working days, non-working days and working hours of each nursing personnel in a year. Table 5.5 Total Number of Working days, Non-Working days and Working Hours of Nursing Personnel per Year Rights / Privileges i Working Hours / Week Given Each Personnel 40 Hours 48 Hours

1. Days of Vacation leave 15 15
2. Days of Sick leave 15 15
3. Legal Holidays 10 10
4. Special Holidays 2 2
5. Days for Continuing Education 3 3
6. Special Privileges Leaves 3 3
7. Off Duties R.A. 5901 104 52
8. Expanded Maternity Leave (RA 105

9. Paternity Leave (RA 11210) 14 Total Non-Working Days /Year 152 100 Total Working Days /Year 213 265 Total Working Hours / Year 1,704 2,120 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Staffing Formula Hereunder are the formula and steps to illustrate on how to calculate the number of staff needed in the in-patient areas of the hospital. Example used is a staffing requirement for a 300-bed capacity tertiary hospital. 1 Categorize the number of patients according to the levels of care needed. Multiply the total number of patients by the percentage of patients at each level of care (minimal, moderate, intensive, and highly specialized). 300 (pts) x .30= 90 patients needing minimal care 300 (pts) x .45=135 patients needing moderate care 300 (pts) x .15 = 45 patients needing intensive care 300 (pts) x .10= 30 patients needing highly specialized nursing care Total 300 patients Find the total number of nursing care hours needed by the patients at each category level. e Find the number of patients at each level by the average number of nursing care hours needed per day. e Get the sum of the nursing care hours needed at the various level. 90 pts x 1.5 (NCH needed at level I)

135 NCH/day 135 pts x 3 (NCH needed at level II)

405 NCH/day 45 pts x 4.5 (NCH needed at level III) = — 202.5 or 203 NCH/day 30 pts x 6 (NCH needed at level IV)

__180 NCH/day Total 923 NCH/day Find the actual number of nursing care hours needed by the givennumber of patients. Multiply the total nursing care hours needed per day by the total number of days in a year. 923 x 365 (days/year) = 336,895 NCH/year Find the actual number of working hours rendered by each nursingpersonnel per year. Multiply the number of hours on duty per day by the actual working days per year. 8 (hours/day) x 213 (working days/year) = 1,704 working hours /year Find the total number of nursing care personnel needed. e Divide the total number of nursing care needed per year by the actual number of working hours rendered by an employee per year. e Find the number of relievers. Multiply the number of nursing personnel needed by 0.15 (for those working 40 hours per week) or by 0.12 (for those working 48 hours per week). 74 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service e Add the number of relievers to the number of nursing personnel needed. Total NCH / year = 36, 895_ = 197.7 or 198 nursingpersonnel Working hours / year 1,704 Total Nursing Personnel x 0.15 = Number of relievers 198 x 0.15 = 29.7 or 30 relievers Total Nursing Personnel needed = 198 + 30 = 228 6. Categorize the nursing personnel into professionals and non-professionals. Multiply the number of nursing personnel according to the ratio of professionals to non-professionals. 228 x .65 = 148.2 or 148 professional nurses 228 x .35=79.8 or 80 non-professionals 7. Distribute by shifts. Supplemental guidelines for staffing standards pattern per hospital category can be found in the “Revised Organizational Structure and Staffing Standards for Government Hospitals, CY 2013 Edition. Shift Options It is important for Nursing Administrators and staff nurses to be aware of the various options in work schedules, as well as the advantages and disadvantages of each. The staff nurse will then be able to select the scheduling pattern best suited to meet the nurse’s need. The Nurse Administrators will be able to select the scheduling pattern best suited to meet the staffing needs of their floor or unit (See Appendix H, DOH Memorandum Circular No. 2016-0032). Eight-Hour Shifts. Planning staffing for employees on the eight-hour shift includes arranging for staffing for three-shifts (3) days, evenings and nights. The day shift begins at 7 am and ends at 3:30 pm, the evening shift begins at 3 pm and ends at 11:30 pm, and the night shift begins at 11 pm and ends at 7:30 am. Full- time employees on the 8-hour shifts work five (5) days a week for a total of 40 hours per week. Staff may work permanent days, evening, or nights, or they may rotate to different shifts. Advantages of the 8-hour shift rotation include: e The traditional work day is 8 hours. Therefore, the staff does not have to adjust to an extended workday. e Staff may have the option of selecting from three (3) shifts, the shift they prefer to work. Hospital Nursing Service Administration Manual 73

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The Administration of Nursing Services Table 5.6 Personnel Staffing Schedule: Eight-Hour Shift 1ST WEEK 28? WEEK 382 WEEK 47 WEEK No. NAME SMTWTFS{SM TWTFS SM TW TFS{|S M TW T A-l Xx xX Xx Xx xX x x B-1 x xX xX xX xX x x xX NOTE: For hospitals following the regulation of the DOLE, they are advised to consider DOLE D.O. # 182 Section 4 “Hours of Work” for item Letter A Section 4. Hours of Work — The normal hours of work of health personnel shall not exceed eight (8) hours a day. (Refer to MC No. 3, s. 2016, Office of the Pres. Phil.) Health personnel in cities and municipalities with a population of at least one million (1,000,000.00) or in hospitals and clinics with a bed capacity of at least one hundred (100) shall hold regular work hours for eight (8) hours a day, for five (5) days a week, exclusive of time for meals, except where the exigencies of the service require that such personnel work for six (6) days or forty-eight (48) hours in which case, they shall be entitled to an additional compensation of at least thirty percent (30%) of their regular wage for work on the sixth day. Scheduling It is a perennial concern of nurse managers, especially nowadays, wherein the nursing workforce is affected by generational differences, new lifestyles, technological skills, family lives, and the integration of work life to personal life. Although satisfying each individual nursing personnel is not feasible, a fair and balanced work schedule can be created while meeting the needs of patients and complying with the organizational policy, rules and regulations. Scheduling is defined by Huber (2013) as the process of determining a set of number and type of staff for a future time period by assigning individual personnel to work specific hours, days or shifts and in a specific unit or area over a specified period of time. Also, according to Rowland (2011), it is a process of allocating the available nursing staff to the days of the week based on the estimated patient care requirements and hospital regulations. It is a timetable showing planned workdays and shifts for nursing personnel. Thus, it provides nursing personnel a clear plan of their work schedule in a specific week in a month. 76 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service Scheduling Systems Fundamentally, scheduling system can be categorized into: Centralized Staffing is a system wherein the power and authority for staffing decisions occur centrally for the entire hospital, commonly the staffing and scheduling office of the nursing service department. Usually under this system, a person in the nursing administration office plans the coverage for all nursing units. A master staffing pattern is developed for all the nursing units and staffing is based on pre-established standard. Decentralized Staffing is a system wherein the power and authority for staffing decisions are methodically dispersed to first-line nurse managers of each nursing unit. Scheduling Approaches Block Scheduling is an approach in which the work schedule for nursing units is planned in block of weeks, oftenly 1 to 4 weeks at a time. It has flexibility because the next block of time need not necessarily follow the pattern of the preceding/following week. Cyclical Scheduling is an improvement of the block schedule in which it has a cyclical repetitive work pattern of 4 weeks. It is known as “team rotation” because the nursing team is scheduled as a unit. This method is used in the team nursing modality of care. Self-Scheduling is an approach in which the nursing personnel sign up for their preferred shifts using staffing and scheduling policy and guidelines. Developing Staffing and Scheduling Policies The Nursing Service Department must have developed staffing and scheduling policies reviewed and updated periodically. These written policies aim to provide a fair and consistent work schedule among nursing personnel. Once a person is work satisfied, it has a positive impact on patient clinical outcomes and staff satisfaction and retention. Staffing and scheduling policies should include the identified list of items that Marquis and Huston (2009) identified. These are as follows but not limited to: e Name of person responsible for the staffing schedule and the authority of that individual if it is other than the employee’s immediate supervisor Type and length of staffing cycle used Rotation policies, if shift rotation applies Fixed shift transfer policies When shift begins and ends Hospital Nursing Service Administration Manual 77

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The Administration of Nursing Services Day of week schedule begins Weekend off policy Policy for change days off Procedures for days-off requests Procedures for vacation time requests Procedures for holiday time requests Emergency request policy Procedures for resolving conflicts on requests for days off, holidays, or requested time off Time and location of schedule posting Tardiness policy Absenteeism policy Low census procedures Rotating to other units policy oo0000 00 o0o0000 Policies and procedures on requesting transfer to other units o Mandatory overtime policy O° Master Rotation Plan is an overall plan which shows rotation of all nursing personnel to various clinical and specialty areas in a given year. However, in hospitals where there are specialty areas, Nurses with special trainings or certification can be assigned only in areas related to their trainings for safety of the patients. (See Appendix I, Sample Master Rotation Plan - Matrix). Master Staffing Pattern is the number and types or categories of staff assigned to the particular units and departments of a hospital or other health care facility. Staffing patterns vary with the unit, department, and shift and with the patient acuity levels (See Appendix J, Sample of Master Staffing Pattern). This helps the Chief Nurse to visualize the equitable distribution of nursing personnel among the various units. It serves as a guide in planning vacation coverage, as a time table for replacement of personnel, as a support for budgeting request, as an aid in forecasting future needs. Daily and weekly time sheets and monthly summary reports of nursing coverage are accompanying tools. Assignment An assignment refers to assigning nurses to specific groups of patients. It is based on their specific knowledge and skills, job description, interest, and patient’s nursing needs. The Chief Nurse or his/her assistant is usually responsible for assigning nursing personnel in the unit. The Senior Nurse gives the daily and specific assignments. Such should be signed by the Supervising Nurse in charge of the ward. Assignments must be made to safeguard patients and make sure they receive adequate and quality nursing care. 78 Hospital Nursing Service Administration Manual

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Staffing in the Nursing Service Characteristics of a Good Assignment A good assignment should be: e Related to the previous work experience and capacities of the worker. Definite and clearly understood and concise. Able to guide the workers in their learning activities. Able to minimize difficulties. Considerate to individual differences. Basic Principles Underlying Patient Assignments e The basic assignment must be made by the Senior Nurse. e Assignments must be planned on a day-to-day basis. e The Senior Nurse must know the nursing needs of each patient and the appropriate time required to care for him/her. e The Senior Nurse must know the capability of each worker and the type of work the latter is expected to do. He/she must also be familiar with the worker’s working habits, such as the worker’s speed, thoroughness and organization of work. The routines of the ward, such as the time when dressing are changed, the time doctors do their rounds and examine patients; and many other factors, such as modalities of care must also be considered. Assignment Techniques Assigning patient care to a member of the nursing team is a responsibility that a conscientious Senior Nurse takes seriously. The first requirement is to make a careful analysis of the needs of each patient. Recent studies and publications that can help the Senior Nurse to sharpen and improve his/her skills in the understanding of the patient and his needs are available. The Senior Nurse must make an assessment of the abilities and capabilities of each member and delegate the work consistent with the needs of the patients based on the patient care classification system and the workers. A standard form of patient assignment should be accomplished by the senior nurse/charge nurse and posted in the bulletin board provided (See Appendix K, Daily Every Shift Work Assignment). Job Description Job Description is a statement setting forth the duties and responsibilities of a specific job and the characteristics of the individual needed to perform it successfully (Rowland and Rowland, 1997). Job description is usually developed by conducting a job analysis that includes examining the necessary knowledge and skills to perform the job. It is a management tool to make certain that responsibilities are wisely Hospital Nursing Service Administration Manual 79

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The Administration of Nursing Services delegated, work efficiently distributed, talents fully used, and morale maintained (See Appendix L, Proposed Job Description of Nursing Personnel). Contents of Job Description A job description contains the basic job-related data, which are as follows but not limited to: Job title Position classification Salary grade Job summary Job duties and responsibilities Reporting relationship Nature of supervision Equipment, machines and tools to be used Working environment

Hazards and risks Qualifications such as:

Educational requirement

Professional license, if applicable

Training and technical skills necessary

Work experience

Philippine Qualification Framework (See Appendix M, Republic Act No. 10968, An Act Institutionalizing the Philippine Qualifications Framework (PQF)). Purposes of Job Description Serves as a basis for recruitment, selection, and job placement of qualified individuals Determines and classifies departmental functions and relationships to facilitate in the structuring of the nursing service organogram Prevents overlapping of duties and responsibilities that might led to work conflict and unproductivity Used as a reference in the performance appraisal of nursing personnel Determines the staff training needs for their personal and professional growth and development Utilized in making up the budget for salary requirement justification 80 Hospital Nursing Service Administration Manual

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Directing the Nursing Service 6 DIRECTING THE NURSING SERVICE At the end of this chapter the Chief Nurse and Nurse Managers shall be able to: Discuss directing as a management function Describe the importance of directing Utilize the elements of directing in the management of the nursing service Identify required resources and delegates duties and allocates work according to one’s capacity Directing is a key managerial function and the heart of the management process that involves giving instructions, guiding, overseeing, counselling, motivating and leading the staff in an organization in doing work to achieve organizational goals. It is a continuous process initiated at management’s top level and flows to the bottom through organizational hierarchy. It refers to the manner of delegating assignments, orders and instructions to the nursing personnel where the latter is made aware of the work expected of the person. Every individual contribution definitely counts but directing leads the way to achieving the goals of the institution. Success in the work is ensured mainly when directing is effectively carried out without discounting the usefulness of other nursing management process. In directing, management skills are put to test, reckoned with and hopefully honed for improvement. Planning, organizing and staffing are meaningless and assume no importance if direction function does not take place. Importance of Directing Establishes direction in carrying out desired action Influences nursing personnel to follow the direction Initiates actions Integrates efforts Becomes a means of motivation Provides stability Enables employee to cope with the changes Helps in efficient utilization of resources SAAS Ye Hospital Nursing Service Administration Manual él

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The Administration of Nursing Services Purposes of Directing Obtain the optimum return from all staff in the interest of the institution and also of employees’ common benefit. Bring personal and professional growth of employees, and promotes motivation and morale among personnel. Bridge the gap of directing and guiding the efforts of others in order to achieve specified objectives in accomplishing tasks towards the attainment of the organization’s goal. Create a direct link between the nurse managers and the nursing personnel through effective communication, decisions, plans and policies to ensure effectiveness of the systems and processes. Maintain standards of services through cooperation by developing cporgination in order to avoid overlapping. Assist in solving problems concerning personnel, administrative and qperations services. Assess continuously the services given, personnel performance, progress made, and suggests changes for improving the work effectively and outcome of the human resource. Principles of Directing To make directing effective in achieving the organization’s goals, there are basic guidelines that serve as principles of directing. Harmony of Objectives. There must be full coordination between the organization’s objectives and the individual’s objectives. Employees work well when they feel that their physiological and psychological needs are met. Unity of Command. An individual should get directions from one superior at a time in order to prioritize his/her work and avoid confusion and conflict. Dual subordination brings disorder and chaos; undermines authority and leads to instability. Appropriate Direction Technique. To supervise effectively, provide able leadership, and motivate, nurse managers must use the direction technique or right medium. Direction technique must be suitable to superiors, subordinates and the situation to ensure efficiency of direction. Use of Motivation Techniques. It is important to get employees motivated to give their maximum individual contribution toward the achievement of organizational objective. Motivation techniques such as pay, incentives, awards, status, promotion, etc. can increase job satisfaction, productivity and quality/excellence of work. Use of the Informal Organization. There must be a free flow of information between the superiors/seniors and subordinates through formal and informal mediums. Special attention should be given to the informal organization to strengthen the formal organization. 82 Hospital Nursing Service Administration Manual

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Directing the Nursing Service Managerial Communication. Nurse Managers must monitor and ensure that subordinates understand correctly their instructions and messages. Direct and personal contact or feedback makes supervision effective and motivating. Appropriate Leadership Style. Leadership is a process of influence exercised on group members by the leader in the work environment. To influence their subordinates, Nurse Managers must provide good leadership. Follow Through/Follow Up. Nurse Managers must monitor the extent to which the framed policies and issued directions have been enforced. Continuous feedback is essential to make necessary modifications in the activities of the management. Characteristics of Directing Initiates Action. By giving directions and instructions the nurse managers get the work started in the organization. Continuous Process. Nurse Managers continuously takes steps to ensure that orders and instructions are carried out properly. Takes Place at Every Level. Directing is a pervasive function for all managers at all levels in all units perform it. It takes place wherever superior- subordinate relation exists. Flows from Top to Bottom. Nurse Managers direct their immediate subordinates and take directions from their immediate superiors. Performance-Oriented. Directing function helps in converting plans into performance. It initiates action in people and makes physical resources meaningful. Emphasizes Human Element. Since human behavior is complex and unpredictable directing function involves studying workers’ behavior and motivating them to work with their best ability. Elements of Directing The elements of directing are as follows: moOw> Supervision Problem Solving and Decision Making Delegation Communication, Teamwork and Coordination Motivation A. Supervision Supervision is an essential part of management, which helps to put plans into action towards the accomplishment of goals. It is providing guidelines for the accomplishment of a task or activity. Hospital Nursing Service Administration Manual 83

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The Administration of Nursing Services It involves overseeing employees at work and it is directly responsible to get things or work done through the operatives by issuing instruction, laying down methods and procedures, guiding, coaching and training the people working under them. It is also a process by which workers are helped by a designated staff member to learn according to their needs, to make the best use of their knowledge and skills and to improve their abilities so that they do their job more effectively and with increasing satisfaction to themselves and the agency. Its main goal is to attain quality care for each patient and to develop the potentials of workers for an effective and efficient performance. A good understanding of administration, clinical competence, and democratic management are essential in supervision. The Role of Supervision e Enforces discipline among workers and handle grievances effectively. Works as a liaison between management and workers. Provides proper working condition to the workers in an organization. Helps in reporting performance progress. Ensures elimination of wastage and reduction of cost. Guarantees the proper functioning of the units. e Helps to secure prosperity for both employer and employees Importance of Supervision e Ensures issuing of instruction. The supervisors make sure that instructions are communicated to all the employees and guide them to work accordingly. e Facilitates control. Supervisor ensures that, employees are using the proper method of work performance to achieve the specified objective. He/she checks subordinates while they are working and provide them frequent and detail instruction when required. e Improves motivation. Acting as a motivator is one of the important roles of the supervisor. He/she associates workers with the objective of providing satisfaction, and tries to create a better work environment, for higher productivity and better quality of work. e Maintains group unity. Supervisor sorts out internal difference and maintain harmony among the workers placed under his control. Thus, play a key role in maintaining group unity. e Serves as a linking pin. A supervisor functions as a linking pin between management & workers. He/she tries to remove the communication gap between superiors and subordinates by passing instructions and orders of superiors to the subordinates, complaints and problems of subordinates to superiors. e Gives feedback. A good supervisor analyzes the work performed and gives feedback to both the workers and management. He suggests workers, the ways 84 Hospital Nursing Service Administration Manual

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Directing the Nursing Service and means of developing work skills and gives reports to management for performance appraisal. Provides training. The supervisor works as trainer for on-the-job trainings. He/she trains workers to perform their jobs effectively and efficiently. Purposes of Supervision To ensure the worker is clear about roles and responsibilities To ensure the worker meets the agency’s objectives To ensure quality of service to clients To assist professional development To reduce stress To ensure the worker is given the resources to do their job Principles of Good Supervision Good Supervision is focused on improving the staff's work rather than on upgrading himself/herself. It is based on predetermined individual needs. It requires self-study by staff members as a starting point in their growth and development. This means that the staff, with the help of the senior nurse, would make an assessment of his/her own ability in giving patient care and set goals based on his/her need for further development. Only when both share in the assessment can they coordinate their efforts. It is planned cooperatively. Objectives, methods of supervision, and criteria for judging success in the attainment of goals are jointly established. The plan is based on the needs changes. Supervision continuously adapts to the changing situations within the division. Good supervision employs democratic methods. The supervising nurse adapts to the experience and ability of the staff member of the existing situation. There is no single method suitable for all persons or all circumstances. The method to achieve the desired outcome should be selected as situation demands. It stimulates the staff for continuous self-improvement. Stimulation results when the individual’s interests are aroused to lead him/her to respond with enthusiasm. Supervision should be continuous, not periodic. Adequate approval, commendation, and recognition for a job well done can encourage the individual to pursue for greater endeavors. It respects the individuality of the staff member. It accepts idiosyncrasies, reluctance to cooperate, and antagonism as human characteristics, just as it accepts cooperation to reasonable and energetic activities. The former are challenges, the latter, assets. It helps create a social, psychological and physical atmosphere where the individual is free to function at his / her own level. It encourages the staff member to contribute in the attainment of his/her objectives. By aiding the staff in achieving success, his / her attitude toward supervision is improved. Hospital Nursing Service Administration Manual 85

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The Administration of Nursing Services Leadership Style for Nurse Managers Task centered. Concentrates on the task more than the performer whom he/she supervises Employee-centered. People-oriented, and is concerned of the needs and welfare of the staff. Autocratic. Critical, cannot tolerate any deviation from norms, lack of quality in work and lack of discipline. Benevolent. Protective of his/her subordinates, keeps telling them what they should do and what they should not. Democratic. Allows subordinates active participations in decision-making. Focuses on providing guidance if requested by subordinates. Types of Supervision Technical supervision uses some of the basic supervisory skills which need to be trained (i.e., group conferences and group discussions). Creative supervision provides maximum adaptation of the situation (such as orientation). Scientific supervision relies on objective study and measurement than personal judgment or opinion. Intuitive supervision needs to maintain interpersonal relationship. The supervision needs a sensitive and intuitive reaction to the emotional needs of another person. Cooperative supervision means full participation of each member of the group in planning action and decisions. Authoritarian supervision centers its responsibility entirely on the supervision with the staff following the orders. Methods of Supervision Direct Supervision. The supervisor is physically present in the workplace, and takes principal responsibility and accountability for the action taken by the supervisee. (i.e., assessment and/or treatment of individual patients/clients. The supervisor observes the supervisee in providing clinical care according to the supervised practice plan. Indirect Supervision. The supervisor and the supervisee share the responsibility for individual patients. The supervisor is easily contacted and available at all times when situation/need arises. It is based on perusal of reports and records maintained by staff; individual conferences or talks, staff meetings and performance during some training sessions, patient’s/relatives’ feedbacks, and patient’s physician’s opinion. Bases for Nursing Supervision Patient’s records and reports, Patient’s history sheets, Treatment records, results of investigations and diagnostic procedures, 86 Hospital Nursing Service Administration Manual

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Directing the Nursing Service Round books, procedure manuals, Medicine ledger book, dangerous drug record and registers, Nursing care plans, Nurse’s Notes, Call books, Admission and discharge registers, Death registers Incident reports, Requisition registers for drugs and supplies Infection prevention and control accomplishment reports Non-conformance and corrective action reports Patient safety checklists and accomplishment reports Other available clinical records RA 9173 Nursing Law RA 6713 Code of Ethics of Public Official and Employees Philippine Professional Nursing Practice Standards of the Professional Regulatory — Board of Nursing Resolution No. 21 S. 2017 (See Appendix N, Professional Regulatory Board of Nursing Resolution No. 21 Series of 2017). Techniques in Supervision e Orientation or on board e Observation e Feedbacks (i.e. Anecdotal Reports) e Purposeful rounds e Nursing Service Administrative Manual e Quality Manual such as: o Policy Manual (on personnel, inter-department, laboratory, dietary and safety) o Nursing Procedure Manual (general and special) co PhilHealth Benchbook edition 2 of the hospital o Kardex o Monthly Schedule of Rotation of Nursing Service personnel o Job Description for administrative, clinical and special areas Tools in Supervision e Organogram e Personnel policies e Communication tools o Checklists Rating Scales Nurses Reports Nursing rounds/Supervisory rounds Anecdotal reports Electronic media such as emails, voicemails, web-based information and internet websites ooo0o0°0 87 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services o Nursing Audit Checklist o Client Satisfaction and Delight Survey o Employees Satisfaction and Delight Survey B. Problem Solving and Decision Making Problem solving is an individual or collaborative process composed of two different skills: to analyze a situation accurately and to make a good decision based on that analysis. Decision-making is the process of making action from alternative making choices by identifying a decision, gathering information and assessing alternative resolutions. Steps in Problem Solving and Decision Making 1. Identify the problem Gather information Weigh the evidence Analyze the causes of the problem Brainstorm for possible solutions/alternatives Decide the best solution Implement the decision Follow up, evaluate and monitor the progress Review the effect of the decision and its consequences $0) 90 TST Gs GN Be 2 Woven throughout the process of administration is the continual requirement of decision-making. Decision-making is the process of developing a commitment to a particular course of action. Two things to be considered when making a decision: the end to be accomplished and the means to be used to accomplish this end. The means is a logical process of discrimination, analysis and choice. The end represents a consensus of opinion requiring a deliberate choice of means to be accomplished. Decision can be made under conditions of certainty, uncertainty or risk. Decision-making relies on the scientific problem solving process, which includes: e Identifying the gap between what is and what should be; e Establishing parameters for solutions such as deciding which factors are acceptable or which are not; e Seeking and testing alternative solutions; e Exploring what could go wrong; and e Evaluating the action. The effective leader/manager is aware of the need for sensitivity in decision-making. Skills in using decision technology are a management function. Two major considerations in organizational decision making are how power affects decision 88 Hospital Nursing Service Administration Manual

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Directing the Nursing Service making and the assumption that management decision needs only to be “satisfying”. The leader, however, strives to make optimal decisions as often as possible. Decision-making, the process of selecting one course of action from alternatives, is a continuing responsibility of nurse managers who are confronted by a variety of situations. Exceptional instances, however, can make decisions more difficult and may require a more mature sense of judgment. Problem solving is a skill that can be learned, and because staff nurses can learn by observing their leaders, good decision making by the leader may do more than solve immediate problems. It can foster good decision-making by staff nurses. C. Delegation Delegation is a major element of the directing function of nursing management. It is an effective management competency by which nurse managers get the work done through their employees. Delegation is a part of management that requires professional management training and development to accept the hierarchical responsibilities of delegation. Nurse Managers need to be able to accept delegation of some of their own duties, task, and responsibilities as a solution to overworked leading to stress, anger and aggression. Delegation is defined as the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome. In order to accept the hierarchical responsibilities, delegation requires professional management training and development. Importance of Delegation 1. Give subordinates a feeling of importance and motivate them for appropriate results. 2. Develop the talents and skills of the subordinates, which can be used for succession planning. Purposes of Delegation

1. Provides appropriate distribution of tasks for safe and quality nursing care.

Promotes individual responsibility and accountability. 3. Allows the nurse to perform more complex patient care and other related services. 4. Reduces workload to prevent burn out. 5. Enhances the knowledge and skills of nursing personnel and other healthcare workers. 6. Promotes cost containment and effectiveness for the health care facility. As Nurse Managers they should learn to accept the principle of delegation to be more productive and enjoy the relationships with the staff. They learn to delegate by purposefully thinking about the delegation process, by doing careful planning for it, by gaining knowledge of clinical nurses capabilities, by planning and implementing effective interpersonal communications, and by being willing to take risks. As they Hospital Nursing Service Administration Manual 89

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The Administration of Nursing Services learn to delegate they become free of daily pressures and time consuming chores and have time to manage. The nursing profession defines and supervises the education, training and utilization of nursing personnel. The nurse-on-duty is in charge of patient care and determines appropriate utilization of any nursing personnel. All decisions related to delegation are based on the fundamental principles of protection of the health, safety, and welfare of the public. A task delegated to the nursing personnel cannot be delegated to others. When a task is delegated, the task must be performed in accordance with standards of practice, the ethico-legal standards of behavior, the policies and procedures established by the nursing profession, the Nursing Law, and the agency (Kelly, 2010). Elements of Delegation e Responsibility. This entails an obligation to fulfill the work assigned to a certain position. e Authority. It is the sum of the powers and rights assigned to a position. The person given more authority to make the most of his/her own decision enjoys work more and derives more personal satisfaction from performing it. In the process of work and sharing to be done, there is a need to ensure that a job is performed appropriately and decisions are made based on factual data. e Accountability. It is the process of establishing an obligation to perform the work and to make a decision within set limits. People will not perform the work unless they can make decisions related to it. The more powers and rights a supervisor can exercise with respect to the work he/she does, including making decisions, the more completely he/she will accomplish that work. The Five Rights of Delegation e Right Task. When determining the right task to delegate, the nurse will determine whether the element of care falls within the guidelines of the established agency policies and procedures and legal regulations for practice. The nurse, then, must consider whether the element of care can be delegated to any other staff member. (See Appendix O, Amended Code of Ethics for Nurses). e Right Circumstance. The delegatee must be provided with necessary resources, equipment, safe environment and supervision to complete the task correctly. e Right Person. To be legally acceptable to perform the element of care, the right staff must possess the necessary competence and education. e Right Direction and Communication. Delegated element of care or task must be clearly and concisely defined, including its objective, limits and expected outcomes. e Right Supervision and Evaluation. This includes appropriate monitoring, intervention, evaluation and feedback as deemed necessary. The delegatee also must comprehend what, how, and when to report back after the delegated 90 Hospital Nursing Service Administration Manual

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Directing the Nursing Service task is complete. Delegatee also need a deadline for task completion for time- sensitive tasks Steps in Delegation i Prepare. Nursing staff cannot deliver quality results if the task delegated to them is not fully thought out or if expectations keep changing. The delegator must take the time and develop the discipline to map out exactly what he/she is asking for. Assign. Clear information (such as objectives, timing or schedule, budget, tools and context) must be provided and, expectations for communication and updates (such as frequency, content and format) must also be set. Confirm understanding and commitment. To make sure that the delegatee understands all aspects of what is required, the nurse manager or delegator can ask the delegatee questions concerning the task or let him/her paraphrase in his/her own words. Since delegation is an act of trust, the delegatee has to be committed to the process, the overall goals for the task and be aware of the expected results and consequences of one’s action. Monitor accomplishment against the assigned tasks. Two-way communication is important in checking regularly the progress of the task to be done. Modify or reorient task if necessary. Open door policy in communication is required to enhance understanding of the task. Good managerial coaching can stimulate productivity, flexibility, and creativity in attaining the desired outcome. Ensure accountability. Ownership of the task by the delegatee involves giving a report on progress made. Pointers to the Proper Delegation of Work Provide clear and specific instructions. Make sure that the responsibilities are clear. Give authority commensurate to responsibility. Keep subordinates informed. Show you have confidence in your subordinates. Be loyal. Delegated Task must be based on Policies Job Description Capabilities of workers Nursing Tasks Commonly Delegated Non-invasive and non-sterile treatments Collecting, reporting and documentation of data such as: o Vital signs, height, weight, intake and output, capillary blood and urine tests for sugar and hematology test results. o Ambulation, positioning and turning. Hospital Nursing Service Administration Manual 91

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The Administration of Nursing Services o Transport of patient within the facility. o Personal hygiene and elimination, including cleansing enema. o Feeding, cutting of food, placing of meal trays. Nursing Tasks Not to be Delegated to Non-Professionals Assessment of patients. This includes physical, psychological and social assessments, which require professional nursing judgment, nursing intervention, referral, or follow-up. Data collection without interpretation is not assessment. Planning of nursing care and evaluation of the client’s response to the care rendered. Implementation that requires judgment. Medications administration. Health teaching and health counseling other than reinforcement of what the Registered Nurse has already taught. Setting the direction of the nursing unit/department. Overall control of area of responsibility. Hiring decision. Maintaining morale and motivation. Giving praises and recognition. Discipline. Highly technical job. Duties involving trust or confidence. Authority to sign one’s name. Performance appraisal of staff Ways for Nurse Managers to Delegate Successfully Train and develop subordinates. It is an investment. Give them reason for the task, authority, details, opportunity for growth, and written instructions if needed. Plan ahead. It prevents problems. Control and coordinate the work of subordinates. Do not peer over their shoulder. Develop ways of measuring the accomplishment of objectives with communication, standards, measurements, and the feedback to prevent errors. Nursing employees want to know the nurse managers’ expectation when there are clear, consistent messages, and behavior that prevents confusion. They understand the expectation from clearly defined jobs, work relationship and expected results. Visit subordinates periodically. Spot potential problems of morale, disagreement and grievance. Coordinate to prevent duplication of effort. Specify goals and objectives. Solve problems and think about new ideas. Emphasize employees solving their own problems. 92 Hospital Nursing Service Administration Manual

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Directing the Nursing Service Know subordinates’ capabilities and match the task or duty to the employee. Be sure the employee considers it important. Agree on performance standards. Relate managerial references to employee performance. Take an interest. Give appropriate rewards. Do not take back delegated task. Assess results. Expect what is clearly and directly asked for as a deadline set for submission of completed reports. The nurse manager should accept the fact that employees will perform a delegated task in their own style. Never delegate an important job to a person who has never done it before. D. Communication, Teamwork and Coordination Communication is the thread that binds an organization together by ensuring a common understanding. It is the complex exchange of thoughts, ideas or information or at least two levels, verbal and non-verbal (Chilly, 2001); involving use of effective listening, non-verbal cues or body language, managing stress and emotional awareness. Organizational charts are the basis of formal communication. Official channels of communication are established between the Medical Center Chief and heads of the different services and between individuals with the services. Importance of Communication 1. oo bo oy Oe Gets the message across Facilitates information Helps in building rapport Promotes education Allows greater understanding Promotes cooperation in treatment and rehabilitation Provides feedback Stimulates new ideas Types of Communication Communication can be categorized into three basic types: if Verbal Communication. This is the most effective means of communication. It provides a means whereby the nursing personnel are best informed of plans, development, changes, and/or problems within the hospital and/of the Nursing Service. Examples are: o Individual conferences to discuss plans, problems and evaluation of personnel performances. 93 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services o Staff meetings, in which administrative matters are interpreted more effectively when explained and discussed in group meetings. o Group conferences, wherein nursing committee develops nursing procedure manuals and plans for in-service education and programs. o Patient contact through regular and frequent patient visits, nurses can explain to the patients the hospital’s different services and nursing care plans for them. 2. Written Communication. It provides a reference from which nurses get instructions or guidance. It serves as a record of standards of practice. Written communication should be easy to understand. Written communication comes in the following forms: o Memoranda or Memo is a brief, informal, written communication that presents the main points of a work related message in conversational language. Memoranda are used to transmit essential information to workers when speed, precision, and clarity are critically important. i.e. Chief Nurse sends memoranda to supervising nurses and senior nurses to keep nursing personnel informed of nursing activities. o Directives are administrative orders, which initiate action and give instructions during an emergency situation. Directives are used to control policy of operation and to coordinate hospital services, e.g. the Chief Nurse issues out a directive concerning standards of nursing care. o Manuals of Operation are written procedures and techniques of each department, which are kept of file for ready reference, e.g., nursing procedure manuals, which are kept at the nurses’ station for ready reference. o Records and Reports are systematized reporting and recording documents, e.g. patient’s record and personnel records. 3. Non-Verbal Communication Dimensions of Communication The dimensions of communications are as follows: e Height. This is the vertical (up and down) or two-way communication. o Downward Communication. The flow of communication comes from higher to lower authority, which starts from the Chief Nurse down to the lowest member of the rank and file. Written communications from the Chief Nurse to nursing personnel are usually concerned with general hospital policies, memoranda, directives and activities. These are coursed across the line through the Supervising Nurses and the Senior Nurses for interpretation, when necessary. 94 Hospital Nursing Service Administration Manual

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Directing the Nursing Service o Upward Communication. It is upward flow of information from frontline staff to immediate superior such as giving of reports and feedbacks. Examples are incident report, 24 hours census report and other pertinent data requiring Chief Nurse’s approval. Breadth. This is the horizontal communication. It is best illustrated in conferences or discussions between the different members of the health team. Communication is concerned with the exchange of ideas, information and feelings. Example includes the total care of patients during conferences with other members of the health team and during on-the job training. Other means of communication includes booklets, brochures, and periodicals, which are also effective in disseminating information to new employees, as these cannot replace personal communication between employees. Depth. This is represented by the communication, which flows in and out of the organization including that of the nursing personnel, visitors, patients, families, friends and the community. Members of the Nursing Service should understand why policies are being issued and how they affect the hospital, the patients, or their families in a given situation. Ways to Communicate Effectively Establish rapport between two communicating parties Listen attentively and avoid interruptions during the course of conversation Use simple words Maintain eye contact Act on the message conveyed Create a receptive atmosphere Avoid bias and judgmental Elicit feedbacks and validate information Acknowledge and appreciate participation in the communication process Coordination is the synchronization and integration of activities, responsibilities, command, and control structures to ensure that hospital resources are used most effectively in pursuit of the specified objectives. Effective coordination of nursing service and patient’s care will lead to patient satisfaction, better quality of service and patient outcomes. Usual methods for transmitting information within the primary work group are face-to-face conversations, memoranda, posters and position papers. Importance of Coordination Ensures unity of direction Creates stronger work force Enhances employee morale and provides satisfaction Facilitates diverse and specialized activities Promotes effective patient care management for the general interest Establishes positive work environment Hospital Nursing Service Administration Manual 95

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The Administration of Nursing Services Principles of Effective Coordination Responsibilities should be clearly defined and understood by all. Channels of communication should be followed. Policies, guidelines and SOP’s on inter-departmental relationships should be established and made available to all. Types of Coordination External. Coordination with the outside parties with whom the organization has the business connections like government, suppliers, customers etc. Internal. Coordination among the employees of the same department or section and among the employees at different levels within the hospital. Horizontal. Coordination that takes place between different departments. Vertical. Coordination that exists between departments where the department heads are asked to coordinate the work of the employees placed under them. Coordinating Activities Hereunder are situations where coordinating management function of nurse manager is exercised: Preparing daily activities and schedules of nursing personnel; Consulting with supervising nurse and other personnel on day-today problems Reviewing twenty-four (24) hour reports of the nursing units Securing special equipment and supplies Attending to unusual occurrences affecting the Nursing Service Taking proper action on regular requisitions Having conference with the professional medical staff Performing supervisory rounds Reviewing personnel progress reports Interviewing and counseling nursing personnel Maintaining daily and cumulative records Scheduling staff conferences Transmitting official information and communication Referring health problems to proper authorities Providing the authorities with written practice reports on the monitoring devices used with corresponding results Coordination with Hospital Services 1. Chief Medical Professional Staff In patient care planning, regular meetings or dialogue between the medical and nursing staff are necessary. Discussions should include finding mutually satisfactory solutions to problems related to the delivery of patient care. 96 Hospital Nursing Service Administration Manual

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Directing the Nursing Service Together, the medical and nursing staff should be able to establish working arrangements, policies and SOPs. To facilitate work, the schedule of the medical rounds should be coordinated with the Nursing Service. Adequate feedback on the progress on the patient’s condition, the patient’s response to medications and treatments, and the prescribed therapies and nursing care determine to a large extent the effectiveness of the planned care. Such problems as the unavailability of the prescribed medicines or adverse reactions to them are to be reported or referred immediately as emergency action or modification may be necessary. e Share knowledge of patients that leads to improved patient outcomes e Formulate and comply to policies, procedures and standards related to patient care e Discuss and solve problems and solutions related to the delivery of patient care e Establish new service lines (multi-specialty services such as oncology care, wellness, and human milk bank services). Coordination with the Radiology Department Requests for X-ray examinations are likewise forwarded to the X-ray service for proper scheduling and specific instructions. This is for certain procedures like X-rays of the genito-urinary tract, cholecystography, gastrointestinal series, etc. Nurses who are not familiar with the preparation for these procedures can always refer to the procedure manual in their unit. Proper notation of any allergies is very important for patients that may receive radiopaque dyes during the procedure. Clarification should be made whether sensitivity test, if indicated, will be done in the patient’s unit or at the X-ray unit. Assistance should be provided when necessary in bringing the patient to the X-ray unit at the scheduled time and when the procedure is over. A patient who has been given instructions about the procedure and the reasons why it is necessary becomes more cooperative and less fearful during the procedure. Also, special consideration for the patient’s safety and comfort must be observed during any procedure. Coordination with the Laboratory Department Requests for Laboratory examinations are forwarded to the laboratory department. Nurses shall check the completeness of data in the laboratory request particularly full name of the patient with middle name, age, gender, Hospital Nursing Service Administration Manual 97

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The Administration of Nursing Services birthday, attending physician, diagnosis of patients, and laboratory test to be performed. Medical technologists usually come to the units/wards for routine blood examinations. Nurses shall direct them to where the patients are located and should be provided the necessary assistance. For those test that need to be STAT, the Nurse shall call the laboratory staff and inform them that there is a STAT request. Specimens such as sputum, feces, urine or those collected after a special procedure such as cerebrospinal fluids (CSF) and biopsies shall be properly labelled with the patient and specimen information and brought by the nursing attendant to the laboratory. For those laboratory examinations that need special preparations, the nurses shall be responsible in giving specific instructions to the patient and/or its guardian, i.e. Fasting Blood Sugar and Lipid Profile. Nurses shall call the laboratory department staff for clarification on the patient preparation needed prior to collection of specimen from the patient. Once laboratory results are verified and released by the laboratory department, they are filed chronologically in the laboratory result sheet on top of each other for easy reference. Coordination with the Hospital Operation Patient Support Services (HOPSS) Coordination with the Hospital Operation Patient Support Services (HOPSS) pertains to both human and material resources. At the unit level, nurses participate in budget planning for staffing, adequate facilities and material resources. Layout of the work areas should be carefully planned to ensure smooth workflow and work simplification. Need for repairs and maintenance of equipment should be promptly reported and recorded in a log book, dated and noted by the receiving personnel. The date and time when the request was acted upon should also be properly noted. Preventive maintenance of all equipment in the units should be regularly scheduled by the Administrative Service. The Senior Nurse should see to it that these are done as scheduled and he/she should make the necessary reminders if they are not accomplished. Overstocking of supplies should be avoided to prevent pilferage and wastage. There should be training on the use of new equipment to maximize the efficient utilization and prevent costly repairs or replacements. The Chief Nurse needs to coordinate with the HOPSS in the following areas: Recruitment, selection and promotion of personnel Procurement of supplies and equipment Maintenance of equipment Housekeeping 98 Hospital Nursing Service Administration Manual

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Directing the Nursing Service The Supervising Nurse/Senior Nurse should report problems related to housekeeping and laundry/linen to the Chief Nurse and coordinate the matter to HOPSS. The Laundry/Linen Service shall be centralized under the Hospital Operation Patient Support Services which shall take charge of the following: e Requisition Laundry Maintenance Distribution Collection of linen The patient care units are the recipients of linen and laundry services. Policies, SOP’s, and mechanism for monitoring and inventory should be established to ensure the adequacy of supplies and minimize, if not to prevent losses of linen. Senior Nurses are not only responsible for requisitioning articles and supplies, but also for ensuring their adequacy and quality. Periodic inspection/inventory should be done to prevent overstocking, overuse, and misuse. Schedules and SOP’s in requisitioning supplies and materials from the Supply Section should be followed to ensure their availability. These services include Human Resource, Procurement, Materials Management, General Services (Linen and Laundry, Housekeeping, and Security), Engineering and Facilities Management, and Public Assistance and Complaint Desk. e Recruitment, selection and promotion of personnel e Development of Project Procurement Management Plan as a basis for Annual Procurement Plan of the hospital. Availability of supplies, materials, and equipment Preventive maintenance of equipment Availability of linen and laundry services Managing of environment and facilities of nursing units Resolving issues and concerns related to hospital information technology e Safety and security of patients, watchers, employees and hospital properties e Handling of customers’ complaints 5. Coordination with the Finance Department These services include coordination with the offices of Billing and Claims, Cashier, Accounting and Budget. e Prepare annual budget for the operations, learning and development programs of the nursing service e Follow up budgetary allocation intended for the nursing service 99 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services e Facilitate compliance for PhilHealth requirements for reimbursement and to prevent disallowances or denied claims 6. Coordination with the Health Information Management Department (HIMD) The Health Information Management Department (HIMD) is in charge of safeguarding, maintaining and processing health records according to the standards set by the Department of Health. The Nursing Service plays a vital role in ensuring the safety, confidentiality, and completeness of all patients’ health records in coordination with HIMD. a. The attending physician, in coordination with the nursing service, shall ensure completeness of the patient’s health record upon the patient’s discharge. It is encouraged for doctors to raise the level of quality health record and sustain a high level of recording. b. The nursing service shall forward all in-patient health records to HIMD staff within 24 hours after patient’s discharge from the nurse station. All health records shall be reviewed for completeness. Receiving logbook shall be maintained. c. For incomplete health records, the HIMD staff shall assist the physician and nurses for completion. d. All diagnostic results of the discharged patients should be properly attached. Pending diagnostic results (histopathology, 2D echo, etc.) shall be forwarded to HIMD. e. To safeguard the confidentiality of the patient’s health records, only those directly involved with patients’ care may hold and have access to the patient’s health record. f. Pre form of Certificate of Live Birth should be prepared by the DR/Nurse/Midwife and should be transcribed by the HIMD staff. g. For the pre form of Certificate of Death, the Nurse on Duty and the Attending Physician shall facilitate preparation and completion of the Certificate of Death. 7. Coordination with Nutrition and Dietetics Service The Senior Nurse is responsible for forwarding the complete diet list of the patients (including the patient’s height and weight) in the units, taking into consideration the prescribed special diets, the patient’s idiosyncrasies for food, allergies or food preferences and religious restrictions. Patients needing special instructions in their diets are referred to the Nutritionist for counseling. Prescribed therapeutic diet (i.c., blenderized feeding) should indicate the following: name of patient, caloric requirement, amount per feeding, date and time prepared, and expiry period. 100 Hospital Nursing Service Administration Manual

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Directing the Nursing Service The Dietary Service assumes full responsibility in the preparation of the patient’s diet and in distributing them to the patients. The nurses should see to it that the right diet goes to the right patient. The patients are assisted in feeding when necessary. Observation should be made on the patient’s appetite, whether they like the food and its preparation. Feedback is given to the Dietary Service if the patient’s food were served on time, including patient comments on presentation and palatability. Pre-discharge planning, is done with the patients who will need a special diet preparation in their homes. Special instruction sheets are given prior to discharge giving enough time for the patients to ask questions or seek clarifications. Foods in season should also be considered and noted for economic considerations, aside from the patient’s preferences or religious restrictions. In compliance with Administrative Order No. 2019 -0033 “Guidelines for the Implementation of Nutrition Care Process in Hospitals “ Nutrition Care Process (NCP) is the systematic problem-solving method that dietetics professionals utilize to critically think and make decisions to address nutrition- related problems and provide safe and effective quality nutrition care. e The nurse shall complete nutrition screening form related to nursing care upon admission. (Refer to AO No. 2019-0033). e Carry out the prescribed medications, diet and fluid requirements and diagnostic tests related to nutrition care; e Document changes in eating/drinking patterns in the patient’s chart and tolerance/intolerance to certain foods, and discuss such matters with the RND. 8. Coordination with the Pharmacy Service Policies regarding the procurement of drugs are formulated jointly by the Administrative, Medical, Nursing Services and Pharmacy. These policies are circulated to all nursing units for notation and guidance of all concerned. The Pharmacy should also provide all nursing units with an established Hospital Drug Formulary including the efficient and effective administration of drugs through the Unit Dose Drug Distribution System (UDDDS). If the hospital pharmacy is open for 24 hours, medicines are procured as they are prescribed. However, in the hospitals where the pharmacy operates only during the day, a minimal amount of emergency drugs are stocked for the afternoon and night shifts. Consumption is properly noted and a report is given to the Pharmacy the following day. Narcotics are prescribed in Special Prescription Forms for Dangerous Drugs indicating the patient’s name and the physician’s professional regulatory and narcotic license numbers. Stocking of narcotics and opiates is discouraged to 101 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services avoid misuse or pilferage. Should stocking of drugs become necessary, these are stocked in locked cabinets with the Senior Nurse keeping the key at all times. The use of narcotics is noted in a special record book for that purpose and is endorsed from shift to shift together with the remaining stock, properly signed by the incoming nurse on duty. A report is made to the Pharmacy the following day. Use of PDEA-prescribed Forms e Requisition Sheet e Controlled Drug Administration Sheet Some hospitals already have the clinical pharmacist. These units are manned by Clinical Pharmacists. They prepare medicines prescribed by the physicians and these are administered by the nurses in the units. Nurses are supposed to know the drugs they administer, their characteristics, their dosages (minimum and maximum dose), and possible reactions to these drugs. If they notice anything unusual, then they should verify from the ordering physician. A reasonable prudent nurse exercises skills in judgment and care. In compliance with Generic Act (RA 6675), the use of generic technologies should be used in all transactions, such as in the patient’s chart prescription and others. The Senior Nurse should maintain a sufficient stock of medicines in the units to meet the emergency needs of patients. It is a joint responsibility of the Supervising Nurse and Pharmacists to monitor the medicines stocked in wards to assure availability of drugs, and prevent overstocking or expiration of drugs. Monitoring of drugs in Emergency Cart should be on regular basis but random and unscheduled by the pharmacist. At daytime, prescribed medicines are taken by the Nurse or Nursing Attendant directly from the pharmacy. Normally, through a properly filled up prescription, twenty-four (24) hours’ supply of medication is requested to be dispensed by the pharmacist upon presentation of a properly filled up prescription. Emergency drugs supply for 48 hours should be made available in all units. This is endorsed to the incoming shift for actual count and measurements. Narcotics are dispensed only with yellow prescription pads. Policies regarding narcotics are determined jointly by the pharmacist and the nurses and circulated for implementation. The pharmacy should provide the Nursing Service with an established Hospital Drug Formulary including the effective and efficient administration of medicines through the (UDDDS). Nurses are not allowed to make prescription (Refer to Hospital Pharmacy Management Manual) 102 Hospital Nursing Service Administration Manual

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Directing the Nursing Service 9. Coordination with the Medical Social Work Service One of the most frequent coordination by the nurses is with the medical social worker. The Medical Social Work Department is an integral part of the hospital that aims to provide a comprehensive professional social work services which is responsive to the psychosocial needs of the patient and their families and make them participate in the realization of their optimal well- being. The health workers such as the nurses shall refer patients to the Medical Social Worker when the following condition, need or situations are observed from the patient and/or their families: e Need for a psycho social assessment of preparedness for a diagnostic or treatment procedure Pre-admission planning Need for concrete services such as, medicine, blood, braces, etc. Financial Problem Adjustment problem o Aggressiveness/ hostility/stubborn and demanding © Refusal to follow rules and regulations o Going Home Against Medical Advice o Withdrawal of patients such as refusal to eat, communicate e Emotional problems met during treatment/hospitalization: o Anxiety due to separation from the family o Refusal to accept treatment o Over-dependent patient o Family disorganization o Unfounded fear of death, disfiguration, etc. e Discharge planning o Patient needing placement o Abandoned cadaver o Transportation problem o Refusal of family to take patient home o Need for home visit e Family Casework o Marital problem o Responsible parenthood, Drug Control and Prevention, o HIV/AIDS - Counseling o Family Life Education, Values Reorientation e After Care treatment o Irregular check-up o Housing problem 103 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services 10. e For Crisis intervention o Trauma patient o Victim of abuse o Death/Loss Nurses shall help the Medical Social Workers in the implementation of the Administrative Order No. 51-A s. 2001, Implementing Guidelines on Classification of Patients and on Availment of Medical Social Service in Government Hospitals, by providing them vital information, that would support their assessment. Nurses come across such information since they spend more time with the patient. Nurses shall likewise help develop a culture of self-reliance by explaining the importance of participation in their treatment costs. Coordination with Other Institutions, Civic Groups and Other Community Agencies Networking or linkages with community agencies, civic organizations or other institutions are often necessary for continuity of care. Two-way referrals are made so that the hospital can have feedback on the action taken by the agency to which the patient is referred. Hospitals with no facilities for special examinations link with hospitals which have these facilities. Special referral forms are utilized for this purpose. Civic organizations or religious group’s services offer their services through visitations, providing religious services, donations of medicines or making of dressing at the Central Supply Room. The nursing service provides assistance whenever necessary. Comprehensive care to patients oftentimes necessitates coordination with other civic groups and institutions. Proper referrals are made. Example: The need for follow-up care and home visits are usually referred to the public health agencies, like health centers. A functional referral system must therefore be ensured. Civic and religious groups also contribute to patient care through their personal services and donations. E. Motivation Motivation is influenced by a complex set of social, professional and economic factors. There are many reasons health workers remain motivated and decide to stay at their jobs. Generally, a health worker will be motivated and express job satisfaction if they feel that they are effective at their jobs and performing well. 104 Hospital Nursing Service Administration Manual

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Directing the Nursing Service It is an internal and external factors that stimulate desire and energy in people to be continually interested and committed to a job, role or subject, or to make an effort to attain a goal. Importance of Motivation

1. Puts human resources into action. Every concern requires physical, financial and human resources to accomplish the goals. It is through motivation that the human resources can be utilized by making full use of it. This can be done by building willingness in employees to work. This will help the enterprise in securing best possible utilization of resources.
2. Improves level of efficiency of employees. The level of a subordinate or an employee does not only depend upon his qualifications and abilities. For getting the best of his work performance, the gap between ability and willingness has to be filled and this helps in improving the level of performance of subordinates. This will result into: a. Increase in productivity, b. Reduction in cost of operations, and c. Improvement in overall efficiency
3. Leads to achievement of organizational goals. The goals of the healthcare facility can be achieved only when the following factors take place: a. There is best possible utilization of resources, b. There is a co-operative work environment, c. The employees are goal-directed and they act in a purposive manner, d. Goals can be achieved if co-ordination and co-operation takes place simultaneously which can be effectively done through motivation.
4. Builds friendly relationship. Motivation is an important factor which brings employees satisfaction. This can be done by keeping into mind and framing an incentive plan for the benefit of the employees. This could initiate the following things: a. Monetary and non-monetary incentives; b. Promotion opportunities for employees; c. Disincentives for inefficient employees. In order to build a cordial, friendly atmosphere in a concern, the above steps should be taken by a manager. This would help in: a. Effective co-operation which brings stability, industrial dispute and unrest in employees will reduce; b. The employees will be adaptable to changes and there will be no resistance to the change; c. Provision of a smooth and sound concern in which individual interests will coincide with the organizational interests; d. Profit maximization through increased productivity. Hospital Nursing Service Administration Manual

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The Administration of Nursing Services 5. Leads to stability of the work force. Stability of workforce is very important from the point of view of reputation and goodwill of a concern. The employees can remain loyal to the enterprise only when they have a feeling of participation in the management. The skills and efficiency of employees will always be of advantage to employers as well as employees. This will lead to a good public image in the market which will attract competent and qualified people into a concern. Needs, wants and desires are interrelated and they are the driving force to act. These needs can be understood by the manager and he can frame motivation plans accordingly. Motivation therefore, is a continuous process based on unlimited needs of the organization. Motivation is important to an individual to:

1. Achieve the personal goals.

Gain job satisfaction. 3. Enhance self-development 4. Increase self-confidence and commitment 106 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service 7 CONTROLLING THE NURSING SERVICE At the end of this chapter the Chief Nurse and Nurse Managers shall be able to: Discuss controlling as a management function Describe the control measures utilize by nurse administrators Implement conflict management in the workplace Employ the principles of change management Controlling, as the last step in the management process, involves setting standards, measuring performance against those standards, reporting the results, and taking corrective actions to ensure the accomplishment of organizational goals. Controlling includes coordination of numerous activities such as decision-making related to planning and organizing activities and information from directing and evaluating each worker’s performance. Importance of Controlling e Helps in achieving the goals of the organization. e Ensures efficient and effective use of organizational resources for achieving the goals. Helps in judging accuracy of standards. Checks mistakes and tells us how new challenges can be met or faced. Improves employee motivation. Ensures order and discipline. Ensures that activities in an organization are performed according to plans. Facilitates coordination in action. Reduces/eliminates risks of nonconformities. Helps in minimizing errors. Helps in improving performance. Corrects deviations. Controls Include: e Policies are broad guidelines for the managerial decisions that are necessary in organizational and departmental planning. e Rules are a set of understood regulations or principles governing conduct within a particular activity or sphere. 107 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Procedures are series of steps followed in a regular definite order to perform a given activity. Self-Control or Self-Regulation is the ability to control oneself, in particular one’s emotions and desires or the expression of them in one’s behavior, especially in adult situations. Discipline is the practice of training people to obey rules or a code of behavior using corrective measures. Rounds is a procedure in nursing education and later practice in which one or more visits to a hospital patient are scheduled by two or more nurses to coordinate care, troubleshoot, respond to patient needs and share insights. Reports refers to an account or statement describing in detail an event, situation or the like, usually are the result of observation, inquiry. Audits are the evaluation of nursing care in retrospect through analysis of nursing records and systemic format and written appraisal by nurses on the quality of content and the process of nursing service from the nursing records of the discharged patient. Evaluation Tool is the methods and device used to assess strategically and recognize the knowledge, expertise and experiences of personnel in their area of assignment.(Self-assessment Tool for Nurse Managers) Task Analysis is a systematic method of collecting data regarding the responsibilities, knowledge and skills associated with acceptable performance within a profession. Quality Control is a procedure or set of procedures implemented by the nursing personnel intended to ensure that the product or perform services adhere to a define set of quality criteria or meet the requirement of the clients or customer. Benchmarking is a quality improvement tool that determines who the best is, who sets the standards and what the standard is, thus, identifying the best practice to be applied in measuring and improving performance in an organization. Used as evaluation and regulation, controlling is the measurement and correction of the performance in order to make sure that organizational objectives and the plans devised to attain them are accomplished. Purposes of Controlling 1. 2. Controls make plans effective. Managers need to measure progress, offer feedback, and direct their teams if they want to succeed. Controls make sure that organizational activities are consistent. Policies and procedures help ensure that efforts are integrated. The administrative process of controlling aims to verify whether everything occurred in conformity with the plans adopted, instructions issued, and principles established. Controls make organizations effective. Organizations need controls in place if they want to achieve and accomplish their objectives. 108 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service 4. Controls make organizations efficient. Efficiency probably depends more on controls than on any other management function. 5. Controls provide feedback on project status. Not only do they measure progress, but controls also provide feedback to participants, as well. Feedback influences behavior and is essential ingredient in the control process. 6. Controls aid in decision making. The ultimate purpose of control is to help managers make better decisions. Controls make managers aware of problems and give them information that is necessary for decision-making. 7. Controls use formal authority to assure the attainment of the purpose of action to the fullest extent possible. It \eads nursing administrators to view the delivery of nursing care as the institutional control of process that brings sick patients back to good health. 8. Controls disclose deviations, identify who is responsible and recommend correction and justify by correcting deviations. It should reflect the nature of the activity and should be forward-looking, objective, flexible, economical, and understandable. Controls should lead to continuous action. Steps in Controlling

1. Establishment of performance standard. Standards are the criteria against which actual performance will be measured. Standards are set in both quantitative and qualitative terms.
2. Measurement of actual performance. Performance is measured in an objective and reliable manner. It should be checked in the same unit in which the standards are set.

Comparing actual performance with standards. 4. Analysis of the cause of deviations. 5. Taking corrective action. Controlling Guidelines for the Nursing Service Administrator e Determine what information requirements of the Nursing Service is needed which will help in: o Evaluating performance o Relating progress to program schedules; o Maintaining status of funds, staff, plan equipment, supplies and materials. Establish a system to generate required data. e Develop standards for cost, quality and production for individual work operations. e Set up a system of control using records and reports to collect and summarize this information for administrative use. e Develop a system of operational audits. e Determine the information required regarding the program’s effect on the community and provide for its collection. e Provide a system whereby management stresses the organization is controlled through the establishment of long-range objectives and short range goals. F 7 i Z 109 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Formulate a human resource development program. Evaluation Principles For a worker’s performance evaluation to be valid, it must be based on his/her job description and performance standards. An adequate and representative sampling of the nurses’ behavior should be observed in the process of evaluating performance. Care must be taken to evaluate his/her usual or consistent behavior. Focusing on, or magnifying an isolated instance of either extremely capable or extremely inept behavior on the part of the nurse should be avoided. The nurse should be provided with a copy of his/her job description, performance standards and evaluation form to review prior to the scheduled evaluation conference so that the nurse and his/her Supervising Nurse can discuss the evaluation from the same frame of reference. In documenting the employee’s performance appraisal, the manager should indicate clearly those areas in which the worker’s performance is satisfactory and those which need improvement. The Supervising Nurse should refer to specific instances of the nurses’ satisfactory and unsatisfactory behavior in order to clarify exactly what types of changes are required in his /her performance. If there is a need to improve the nurse’s performance in several areas, the manager should indicate which area should be given priority by the nurse. The evaluation interview should be scheduled at a time convenient for both the nurse and the manager. It should be held in a pleasant surrounding and should allow time for both parties to ask questions and discuss the evaluation at length. Control Measures Utilized by the Nursing Service Administrators Performance Appraisal is a systematic general and periodic process that assesses an individual employee’s job performance and productivity in relation to certain pre- established criteria and organizational objectives. For example: Strategic Performance Management System (SPMS). This is done every six months. Performance appraisal is a systematic process of evaluating an individual employee’s performance in terms of his productivity with respect to the pre- determined set of objectives. This is when the performance of the employee is assessed and discussed in thorough detail, with the manager communicating the weaknesses and strengths observed in the employee and also identifying opportunities for the employee to develop professionally. It gives the employee an opportunity to reflect on the duties that were dispatched by him, since it involves receiving feedback regarding their performance. It enables organizations to take appropriate steps for the further development of employees and the company itself. 110 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service e Performance Appraisal aims to measure how well an individual is doing in their job against a set of criteria. e Performance management is a framework for assessing, maintaining and improving organizational, functional work team and individual performance. It is the heart of the human resource system because information produced from it is useful in human resource planning, management and decision making process. Employee Discipline refers to the regulations or conditions that are imposed on employees by management in order to either correct or prevent behaviors that are detrimental to an organization. Code of Conduct is a set of rules outlining the social norms and ethical rules and responsibilities of, or proper practices for, an individual, party or organization. Quality Management System (QMS)is a formalized system that documents processes, procedures and responsibilities for achieving quality policies and objectives. It helps coordinate and direct organization activities to meet customer and regulatory requirements and improve its effectiveness and efficiency on a continuous basis. Continuous Quality Improvement (CQI) is a process of continuous improving a system by gathering data or performance and using multidisciplinary team to analyze the system, collect measurements, and propose changes. With the Department of Health mandate of providing quality health services especially to the poor, performance management must yield optimal result. The DOH uses the Strategic Performance Management System (SPMS) as embodied under MC No.6 s.2012 which is focused on linking individual performance in relation to the agency’s organizational vision, mission and strategic goals. It is envisioned as a technology composed of strategies, methods and tools for ensuring fulfillment of the functions of the offices and its personnel as well as for assessing the accomplishments. It is a mechanism that ensures that the employees achieve the objectives set by the organization and the organization on the other hand, achieves the objectives that it has set itself in its strategic plan. The Strategic Performance Management System (SPMS) follows the four-stage PMS cycle: performance planning and commitment, performance monitoring and coaching, performance review and_ evaluation, performance rewarding and development planning. Importance of Performance Appraisal e Ensures consistent standards are used to evaluate job-relevant behaviors. e Helps supervisors to understand the validity and importance of the selection procedure. e Serves as a motivation tool. 111 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Provides important and useful information for the assessment of employee’s skill, knowledge, ability and overall job performance. Helps employees understand and accept skills of subordinates. Serves as a system to measure and evaluate the performance level of each employee in an organization. Principles of an Effective Management of Performance Appraisal The system should be simple and effective, efficient and administratively feasible. The procedures and uses of the system should be understood and agreed on by line managers and employees being rated. Factors to be rated should be measurable and agreed on by managers and subordinates. Raters should understand the purpose and nature of the performance review. They should be taught to use the system, observe, and write notes, including a critical incident file; organize notes and write evaluations that include examples of evidence; edit their reports; and conduct review interviews. Raters should understand the meanings of the dimensions rated, including the dimensions’ relative weights. The process should be organized and used to manage employees on a daily basis according to their needs to be coached. Praise or suggestions for improvement should be done at the time of the event. Standards of performance should be set and modified at the time of the event. Performance standards should be valid, reliable and work output, not habits and traits such as loyalty, should be measured not unless the habits or traits are described by specific examples of observed behavior. Quality, constant innovation, and functional barrier distraction should be emphasized. Appraisal should be less time-consuming through time management: daily feedback, preparation time for annual or semiannual evaluation, execution time that is spread out, and group time for consultation and coordination of appraisal criteria with peers. The last provides for fairness and equity throughout the organization. Performance goals should be straightforward, emphasizing the manager’s desired results and considering what is important to the continuing success of the business. To get employees to buy into performance improvement, managers should create a relationship to both individual and organizational performance improvement and, in turn- to add value to the success of each individual —the department and the organization; identify a measurement for each critical point in the process; and present reports and celebrate monthly at staff meetings. 112 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service Steps to an Effective Performance Appraisal 1. Review the ratee’s job description, assigned tasks if any and the unit’s targets based on organizational goals. 2. Examine factors which may have affected the ratee’s job and his /her performance such as issues on attendance, deviation from standard of care. Identify problem areas and consequences. 3. Analyze past performance rating and previous discussions to determine improvement based on progress review. 4. Focus on performance and accomplishments rather on personalities. 5. Evaluate current employee’s performance with emphasis on the specific events or instances of the employee’s achievements and deficiencies in his/her work. 6. Allow the ratee to express his/her feelings and ideas; manage resistance if any. 7. Direct the interview towards the future performance, using the past as the background. 8. Win the confidence of the employee by showing interest in the employee’s development. 9. Discuss suggestions / actions for improvement and capitalize on the employee’s strengths and potentials. 10. Allow two-way communication for mutually agreed solutions. 11. Act as a coach and mentor. 12. Conclude the interview with a program of development. 13. Monitor and evaluate performance regularly. Types of Performance Appraisal Tools Anecdotal Recording describes the positive and negative performance and behavior of a person, or in validating technical skills and interpersonal relationships. Example of Positive Performance - commendation from patients, supervisors, and doctors specially patients issues Example of Negative Performance - incident reports on safety issues or patients concern, non-conformity to process It includes the following: e A description of the particular occasion e A delineation of the behavior noted including answers to the questions who, what, why, when, where and how, and e The evaluator’s opinion or assessment of the incident or behavior. Performance Management System (PMS) It is a shared understanding of what will be achieved, how it will be achieved and managing people in a way that will increase the probability that it will be achieved. Set of processes means that PMS has four stages. Shared understanding means that there should be an agreement between the supervisor and subordinate or rater and ratee. Also, managing people means that there should be monitoring and coaching to 113 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services ensure that timely and appropriate steps are taken to keep the PPAs on track and objectives/goals are met.SPMS links individual performance to division performance to office performance then to organization’s Vision, Mission, Goal (VMG). What will happen if an individual is not performing? In private sector-no profit-bankruptcy while in public sector-no service-no effect. Through the DOH Scorecard, the basis of targets and commitments found in Office Performance Commitment and Review (OPCR), it will be cascaded down to Division Performance Commitment and Review (DPCR) and then to Individual Performance Commitment and Review (IPCR)(See Appendix P, Guidelines in the Establishment and Implementation of Agency Strategic Performance Management System (SPMS). Uses of Performance Ratings

1. Performance-based security of tenure.Security of tenure is not absolute. It depends on performance. If an employee obtained unsatisfactory rating for 2 consecutive semesters, it warrants separation from the service. Further, 1 Poor rating warrants separation from the service.

Grant of Rewards and Incentives. SPMS rating of at least satisfactory is a prerequisite for benefits like PBB, Mid-Year Bonus, Year-end Bonus and Longevity Pay. 3. Basis for Personnel Actions-SPMS rating of at least Very Satisfactory for 2 consecutive periods is a requirement for promotion, trainings, scholarship grant, study leave and other Human Resource actions. Key Players 1. Head of Office assumes the primary responsibility for the performance in his/her office. 2. Division Chief assumes joint responsibility with the Head of Office in ensuring attainment of performance objectives and targets; do coaching and monitoring and assesses individual employee’s performance 3. Employees- act as partners of management and their co-employees in meeting organizational performance goals. Performance Management System has four (4) cycle:

1. Performance Planning and Commitment. This is done before the start of the rating period. For example, for July-December rating period, it should be done in June. It is when the supervisor and subordinate meets and agrees on the output and success indicators. Output-Performance Contract.
2. Performance Monitoring and Coaching. This is done to ensure that timely and appropriate steps are taken to keep the PPAs on track and and in the end, the deliverables are met.
3. Performance Review and Evaluation. The Performance Contract is revisited and assess the performance level based on the approved success indicators.
4. Performance Rewarding and Development Planning. The competency of employee is assessed vis-a-vis the competency requirement of the job. 114 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service Performance Performance Planning and Rewarding and Commitment Development Planning Perfomance Performance Monitoring Review and and Coaching Evaluation ~~ Figure 7.1 Performance Management System Cycle Characteristics of an Evaluation Tool The evaluation tool should be objective, reliable and sensitive. Objectivity means that the evaluation tool is free from bias. Reliability refers to the accuracy or precision of the tool such that it will produce the same results if administered twice. Validity refers to the relevance of the measurement to the performance of the employce while sensitivity means that the instrument can measure fine lines of differences among the criteria being measured. Simple Ranking This evaluation tool requires the evaluator to rank the employee according to how he/she performed with his co-workers with respect to certain aspects of performance. A particular staff nurse may be ranked by the Supervising Nurse as having demonstrated the highest quality of performance among the seven staff nurses in the units with regard to patient care measures or third from the top of the same group, with regard to the quality of his/her contribution to a research project being carried out in the units. Performance Checklist This consists of a list of performance criteria (one for each of the most important tasks in the employee’s job description) with corresponding blanks wherein the evaluator is asked to indicate for each criterion, whether the nurse has or has not the desired or approved behavior. A quick glance at the completed form reveals the overall quality of the nurse’s total work performance. 115 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Graphic Rating Scale This includes a series of items representing different activities or tasks included in the nurse’s job description. The Supervising Nurse is asked to indicate the quality of the nurse’s performance for each activity by checking the appropriate point on a numerical scale or by selecting the appropriate phrase in a series of phrases. (For example: Using the 4-point Likert scale). Recording and Reporting Records are hospital administrative tools used in collecting data directed towards the attainment of the objective of its sections and department. They are the sources of cumulative and relevant information that may be used as basis for patient management and the effective planning of activities for training, research and decision-making. Records are valuable legal documents and so it should be handled carefully and properly accounted for. It contains a written evidence of the activities of an organization in the form of letters, circulars, reports, contracts, invoices, vouchers, minutes of meeting, books of accounts and others. Reports are oral, written or audiotaped exchange of information shared between caregivers. Common reports given by nurses include change- of- shift reports, telephone reports, transfer reports, and incident reports. Purposes of Records 1. Provides staff member, administrator, and other health team members with essential data for program planning and evaluation. 2. Serves as tools of communication between health workers, the family, and other development personnel. 3. Provides data to forecast the long-term changes for service improvement. Reports are verbal or written informational work in a particular matter made with an intention to relay events, situations in a presentable manner for decision making. Reports can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/or the agency. Reports may be in the form of an analysis of some aspects of care. These are based on records and registers and so it is relevant for the nurses to maintain the records regarding their daily case and service load and activities. Thus the data can be obtained continuously and for a long period. 116 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service Mandatory Reports e Bi-Annual Report to be submitted at HFDB) January to June and July to December) Consumption Report Inventory Report Daily 24hrs Report Sentinel Events Incident Reports Others Importance of Recording and Reporting 1. Measures, monitors and controls to enhance the workforce performance 2. Improves communication among managers, subordinates, customers and other stakeholders 3. Sets benchmark for quality improvement of services 4. Ensures compliance to statutory, regulatory and other legal requirements Employee Discipline It is a form of self-control through which the individual actions are in accordance with the institution’s code of behavior. It is also the process of generating the employee’s compliance with institutional rules and regulations. Disciplinary action may be ineffective owing either to the methodological weakness or procedural omission on the Chief Nurse’s part. The methodological problems usually spring from failure to document the interview properly. Procedural problems result from failure to apply timely discipline and failure to follow due process in applying (Refer to 2017 Rules on Administrative Cases in the Civil Service). Principles of Discipline e Discipline should be administered promptly, privately, objectively and consistently, following due process. e Discipline should be progressive and should be preceded by individual conference. e Instituting disciplinary action should be observed with extreme caution for it causes serious consequences for the employee like loss of employment and damage to professional reputation. e The superior should recommend (with initial findings and data) the disciplinary action to appropriate authority if necessary like grievance committee, legal office, human resource department and others. Employee’s Code of Conduct The Code of Conduct applies to all employees of an organization including officers, directors, and employees of the hospitals and its subsidiaries and affiliates. It is a key 117 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services governance best practice that guides your policies, procedures, and practices. It is the best interest of your hospitals and stakeholders that you adopt and implement a Code of Conduct to, among other things, help ensure compliance with standards, laws and regulations. For effective discipline to take effect, the employee should be aware of the institutional rules and regulations that govern his/her behavior. Such rules should be clear and concise and should be incorporated in an employee’s handbook or manual that is given to new workers during induction or orientation. Employee’s Manual code of conduct must be available in all hospital units. It should be regularly reviewed and discussed with employees by their immediate superior. The 2017 Rules on Administrative Cases in the Civil Service is used as a basis in processing and imposing appropriate disciplinary action. Disciplinary Conference It is an informal administrative meeting between an accused and complaint party. It is a combination of directive and non-directive interviewing techniques used in conducting a disciplinary conference. Giving criticism is a difficult and unpleasant task. A disciplinary conference is anxiety-provoking for both the supervisor and the employee who is being reprimanded. It is the supervisor who carries the greater responsibility for the success of the conference. (Refer to 2017 Rules on Administrative Cases in the Civil Service) Disciplinary Conference should be conducted in the following manner: e The supervisor should prepare for the interview by constructing a written outline to guide the discussion. It may begin with a clear statement of the rule or standard violated to institutional functioning, the corrective actions expected of the employee, the amount of time the employee is allowed to make up for his/her shortcoming, and further discipline to be administered if prescribed behavioral changes do not occur. e The session should be short, simple and direct to the point. e The supervisor should be in control of the interview and should focus discussions on the employee’s actions rather than on his/her motive and attitude. e Should maintain strict objectivity in discussing the rule violated and the disciplinary action to be taken. e The disciplinary conference must be carefully documented and signed by both parties, as a basis for alter steps in progressive discipline. 118 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service Progressive Discipline It is a process for dealing with job-related behavior that does not meet expected and communicated performance standard. The primary purpose of progressive discipline is to assist the employee to understand that a performance problem or opportunity for improvement exists.The goal of progressive discipline is to get the employee’s attention so that he or she understands that employee performance improvement is essential if they want to remain employed. Steps of Progressive Discipline a. Verbal Counseling. Counsel the employee about performance and ascertain his or her understanding of requirements. Ascertain whether there are any issues that are contributing to the poor performance. These issues are not always immediately obvious to the supervisor. Solve these issues, if possible. b. Written Warning. The employee for poor performance. Tell the employee that you will document the next steps in progressive discipline process and that termination can result at any point in the process when the employer believes that the employee is unable to improve despite repeated warnings. Document the conversation. c. Written reprimand. The written reprimand corrects the behavior of a tardy employee. It is an acknowledgement that the counseling is not working. It is one of the steps available to supervisors and managers as they work with employees to correct attendance problems and other work related problems. It provides documentation for the employer. It is a serious call for immediate improved performance by the employee. d. Preventive Suspension is a disciplinary measures for the protection of company’s property, pending investigation of any alleged malfeasance or misfeasance committed by the employee. e. Termination of Employment is when the employees job ends. Voluntary termination includes resignation or retirement. Employees can be terminated for cause, in that case, an employee is fired or dismissed from their job. Due Process A citizen's fair treatment within the rules of a government's legal system based on the Civil Service Steps of Progressive Discipline. The Chief Nurse should adhere to the principles of due process according to Civil Service Rules and Regulation, and ensure a fair treatment of his/her subordinates. 119 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services Discharge Dismissal Penalty Suspension Preventive Suspension Written Reprimand Verbal Reprirnand Counselling Figure 7.2 Steps of Progressive Discipline Handling Complaints When a customer feels strongly enough that his or her expectations have not been met, he or she may make a complaint. A complaint is when a customer brings a problem to the attention of the organization and expects some redress, probably over and above simply supplying the original product or service that was the cause of the complaint. Complaints are often used by regulators as one measure of the success of the organization’s customer service (See Appendix Q, Rules of Procedures in Handling Consumer Complaints for Violation of the Consumer Act of the Philippines (Republic Act No. 7394). The five (5) rules of complaints handling for organizations

1. Have a strategic plan. Have a clear, flexible welcoming and open policy on complaints. A complaint is a gift when a customer gives up their time to help you improve your organization.
2. Train your staff and management in complaints handling. Give them confidence to tackle the difficult customers and support in their actions. Excellent complaint handling isn't easy and can sometimes be stressful and feel unrewarding. Confirm its importance in providing great customer service.
3. Give complaining enough priority and authority. Staff should be aware that complaints are a top priority item for your operation, and anyone who deals with them must have sufficient authority to resolve them completely. 120 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service 4. Ensure that you can process complaints from all sources. There are 4 main ways to complain — in person, by telephone, by mail, by email/internet. Your organization must be able to handle all of these efficiently. 5. Set up processes to log and analyze all complaints and share with everyone. You can learn a lot about problems with internal processes, training, specific employees/managers, and product for free. Ten (10) Processes and Actions for Setting up your Complaints Handling 1. Thank the customer for complaining. Say that you are sorry that the problem has happened. This is not an admission of guilt and it does demonstrate respect for the customer. 2. Put yourself in the place of the customer. This will instantly give you an advantage, as you not only will have more empathy with the customer, but also you know your business better than them and so can hopefully see the solution quicker. 3. Start with the view that the customer has a valid point, not that he/she are trying to rip you off. \t is true that there are some professional complainers, but they are in the minority. If you are a local store, you probably know them anyway. Accepting the customer may well have a point can trigger ideas for an acceptable resolution. 4. Get all the facts first. Let the customer give you all of the information. This will help you fully understand the situation and, if the customer is emotional, this will give them time to calm down. Don't offer the complainant a free gift straight away. It's very tempting to give the customer a gift, or vouchers. In many cases it is good service, but too often it is done instead of solving the problem, which can lead to more complaints about the same thing because it hasn’t been fixed. 5. Correct the mistake. All of the other suggestions are pointless if you don't fix the problem. Make sure that your definition of the right fix is the same as the customer's. 6. Learn from every complaint. Fix the process: Train staff in the issue and eliminate the fault. Wherever possible let the complaining customer know that they have helped you resolve a problem. They'll come back again and again and will probably spread the word. 7. Minimize reasons for complaints. Do you have a continuous improvement culture? Do you check customer (and employee) satisfaction regularly? Do you check the quality of the goods sold in your organization? It costs at least 5 times as much to gain a new customer than keep an existing one, and takes 56 days on average. Keeping this complaining customer should be the top priority, and at these cost ratios you can afford to be generous in your time and effort. 8. Always respond. In person complainers hopefully always get dealt with, but make sure that everyone who complains on the telephone, by letter, or by E- mail gets a rapid and appropriate response. 9. Listen to your staff. They nearly always care about your company and doing a good job and are much closer to the customers than you are. Ask their views s ss 121 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services regularly and make changes when they are sensible. Make sure their complaints are handled too. 10. Lead by example. It’s not that your staff don't listen to what you say, it’s that they do listen, so make sure that you are always setting the right example, and giving complaints your personal priority. Reward good complaints handling. Conflict Management A culture of a quality and safe health delivery system is the primary aim of the Nursing Service in any health care facility. The American Organization of Nurse Executives (AONE), the professional association for nurse executive and nurse managers prioritizes evidenced-based management practices. The nurse managers are provided the challenge to clearly understand the Nursing Service culture to handle conflict, the impact of conflict in the positive development of the service, the barriers to manage conflict, the costs of conflict and the strategies utilized in conflict resolution. This is further defined as an expressed struggle between at least two interdependent parties, who perceived incompatible goals, scarce rewards and interference from the other party in achieving their goals. They are in a position of opposition in conjunction with cooperation. (Linda Roussel, 2006) It is further defined by Marquis and Huston (2008) as an internal or external discord that results from differences in ideas, values, topics or feelings between two or more people. There are three primary categories of conflict: Intrapersonal, interpersonal and inter group: e Intrapersonal conflict occurs within the person. It involves an internal struggle to clarify contradictory values or wants. For managers, intrapersonal conflict may result from the multiple areas of responsibilities to the organization, subordinates, consumers, the profession, and they may sometimes conflict, and that conflict may be internalized. Being self-aware and conscientiously working to resolve intrapersonal conflict as soon as it is first felt is essential to the leader’s physical and mental health. e Interpersonal conflict happens between two or more people with different values, goals and beliefs. The person experiencing this conflict may experience oppositions in upward, downward, horizontal, or diagonal communication. e Inter-group conflict occurs between two or more groups of people, department, or organizations. An example of inter-group conflict might be two political affiliations with widely differing or contradictory beliefs. Stages of Conflict Conflict management may depend on recognizing how far along the parties are in a particular conflict. In general, conflict seems to go through three major stages. 122 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service e Latent conflicts are characterized by the recognition of some underlying tensions. People have not felt the need to take sides yet; the conflict is not high polarized. At this stage, some, but not all, participants begin to be aware of the coming conflict. e Emerging conflict is when all parties involved acknowledge that a disagreement of dispute exists. At this stage, there is potential for the conflict to escalate. People sense that tension is building in all potential participants. e Manifest conflict is the stage of open, ongoing conflict. The people involved may have already begun to seek ways to resolve or deal with. In managing conflict, the following ideas may be considered: Point those in conflict toward common goals. Use problem solving. Focus on the issues not personalities. Keep everyone informed about what is happening. Have rewards for success, share responsibility for failure. The Nurse Managers have several interpersonal relationships wherein persons have various values, beliefs, backgrounds and goals. Conflict is managed via the style and the strategy chosen by the conflict manager. Several conflict styles and strategies exist, meaning that individuals have choices. The ability to select among styles and strategies if something is not working provides flexibility for the person dealing with conflict. Conflict takes place between individual staff, within the unit or within the department. (Anita Finkelman, 2006). These can occur inter-unit and interdepartmental which can affect the entire health care facility as a whole or the Nursing Service in particular. It can occur between multiple between or within teams or units. Conflict further refers as the tension arising from compatible needs in which the actions of one frustrate the ability of the other to achieve goal (Boggs, 2003). Causes of Conflict A, Organizational Conflict may emanate from misinformation and misconception. The other party may have information that the other does not have or the other party may have different information B. Antecedent Sources of Conflict e Role conflict when two nursing staff have equal responsibilities, but actual boundaries are unclear or when they are require to fill simultaneously two or more roles that show inconsistent or contradictory expectations e Goals incompatibility e Nursing staff experience problems of distribution of scarce resources 123 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services e Values Task pertaining to outputs or individual or group nursing personnel become inputs of another individual or groups are out puts shared by several individuals or groups e Interest in outcome e Individual’s need for autonomy conflicts with another’s need for regulating mechanism Con flict Management Checklist vY Identify the boundaries of the conflict, the areas of agreement and disagreement, and the extent of each person’s aims. Y Understand the factors that limit the possibilities of managing the conflict constructively. Be aware of whether more than one issue is involved. Be open to the ideas, feelings, and attitudes expressed by the people involved. Be willing to accept outside help to mediate the conflict. SAS Conflict Management Strategies 1. The defensive mode produces feelings of winning in some and loss in others. Several conflict resolution strategies adopt a defensive mode. Sometimes if creative problem solving and compromise fail, this may be the only way to decrease some of the destructive effects of conflict. Or a defensive mode may be used initially to gain time to calm down or to think about how to proceed. Foliowing are ways to defensive solve a conflict: 1.1 Separate the contending parties. For example, people may be assigned to different shifts or teams or different days off and on. 1.2 Suppress the conflict. For example, people may decide not to talk about their differences. 1.3 Restrict or isolate the conflict. For example, the parties can agree to disagree about a conflict and move on to items that they do agree about. 1.4 Smooth it over or finesse it through an organizational change. For example, sometimes it is possible to solve conflicts by restructuring around the issue. 1.5 Avoid the conflict to diminish the destructive effects. For example, people can change the subject whenever the conflict arises or avoid the party or parties involved. Compromise mode, each party wins something and loses something. In the settlement, each side gives up a part of its demands. Thus each side may “go halfway” or “split the difference”. A compromise comes about when sides want harmony or an end to the conflict and are willing to give up something to settle the difference. Creative Problem-Solving mode produces feeling of gain and no feelings of loss for all conflict participants. All parties work together collaboratively to arrive at a solution that satisfies everyone, and all parties feel that they win. Creative 124 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service problem- solving is the most effective mode of conflict management. As part of the creative problem-solving process, the following five steps for conflict management can be identified: 3.1 Initiate a discussion, timed sensitively and held in an environment conductive to private discussion. 3.2 Respect individual differences. 3.3. Be empathic with all involved parties. 3.4 Have an assertive dialogue that consist of separating facts from feelings, clearly defining the central issue, differentiating viewpoints, making sure that each person clearly states their intentions, framing the main issue based on common principles, and being an attentive listener consciously focused on what the other person is saving. 3.5 Agree on a solution that balances that power and satisfies all parties,so that a consensus on a win-win solution is reached. Conflict Handling Intentions Building on the Blake and Mouton model, Thomas (1976) reported that conflict has two dimensions, each representing an individual’s intention with respect to a conflict situation. The dimensions are: 1. Assertiveness (satisfying one’s own concern 2. Cooperativeness (attempting to satisfy another’s concerns). When handling conflict, individuals vary in their degree of cooperation and assertiveness. The resulting behavior are competing, collaborating, compromising, avoiding and accommodating. Competing is an assertive strategy in which an individual’s concerns are satisfied at the other’s expense. Collaborating is an assertive, cooperative strategy in which individuals work together to find a mutually satisfying solution. Compromising incorporates both assertiveness and cooperating. In compromising, each individual involved in the conflict must give up something to resolve the situation. Avoiding is an unassertive, uncooperative strategy used when an individual postpones or sidesteps an issue. Accommodating is an umassertive, cooperative strategy used when an individual focuses on the concerns of the other while neglecting his own. Conflict Resolution Strategies

1. Avoiding. This is the strategy of avoiding conflict at all costs. Some people never acknowledge that a conflict exists. The individual’s posture is “if I do not acknowledge there is a problem then there is no problem”. It is sometimes reflected in the phrases “leave well enough alone.” . : , aoe . 125 Hospital Nursing Service Administration Manual

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The Administration of Nursing Services I 10. 11. Withholding or Withdrawing. In this avoidance strategy one party opts out of participation. He or she withdraws from the situation. However, this strategy does give individuals a chance to calm down or to avoid a confrontation. Smoothing Over or Reassuring. This is the strategy of saying “Everything will be OK” by maintaining surface harmony, parties do not withdraw but simply attempt to make everyone feel good. It is similar to “smoothing ruffled feathers.” Smoothing over or reassuring strategies use verbal communication to defuse strong emotions. Accommodating. This strategy is used when there is a large power differential. The more powerful party is accommodated to preserve harmony or build up social credits. This means that the party that the party of lesser power gives up his or her position in deference to the more powerful party. Accommodation may be used when one party has a vested interest that is relatively unimportant to the other party. “Kill the enemy with kindness” is the related phrase. Forcing. This technique is a dominance move and an arbitrary way to manage conflict. An issue may be forced on the table by issuing orders or by putting it to a majority-rules vote. The hallmark phrase is “Let’s vote on it.” Forcing is an all-out power strategy to win while the other party loses. Competing. This is an assertive strategy in which one party’s needs are satisfied at the other’s expense. Competing is an all-out effort to win at any cost. It is sometimes reflected in the phrase “Might makes right.” Competing strategies tend to follow rules and be similar to games and athletic contests. Applying for a job is a form of competition. Conpromising — this strategy is called “splitting the difference.” It is useful when goals or values are markedly different. It is a staple of conflict management. Confronting. This technique is called assertive problem solving and is focused on the issues. Individuals speak for themselves but in a way that decreases defensiveness and allows another person to hear the message. It is a staple of conflict management but requires courage. “I” messages are used; “you” messages are avoided. Collaborating. This is an assertive and cooperative strategy in which the parties work together to find a mutually satisfying solution. It is involved with the phrase “two heads are better than one.” Bargaining and negotiating. These strategies are attempts to divide the rewards, power, or benefits so that everyone gets something. They involve both parties in a back-and-forth effort at some level of agreement. The process may be formal and informal. Problem solving. This strategy’s goal is to try to find an acceptable, workable solution for all parties. It is designed to generate feelings of gain by all parties. The problem-solving process is employed to reach a mutually agreeable solution to the conflict. 126 Hospital Nursing Service Administration Manual

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Controlling the Nursing Service Mediation is a conflict-resolution process in which a neutral person facilitates communication, the development of understanding, and the generation of options for creative dispute resolution (Moore, 2003). Gerardi (2004) noted that mediation is a useful process to use when the goal of preserving the working relationship is as important as resolving the substantive problems. Although not all conflict situations require mediation, mediation techniques can be used to prevent escalation of conflicts. Effective techniques for improving collaboration and resolving conflicts include listening for understanding, reframing, elevating the definition of the problem, and creating clear agreements. Mediation techniques can be integrated into manager’s practice to assist nurses in recognizing issues and addressing the actual needs of co-workers to prevent escalation of conflicts (Gerardi, 2004) Change Management There are innovations made by nurse managers. As a progressive leader as well as transformational leader, there is a need to embrace the challenges of change. To meet the challenge of on-going change successfully, insight and strategies that support change management initiatives at all organizational levels are needed, a myriad of change management models, theories, tactics and processes exist to help leaders plan and implement change. Importance of Change Management e Serves as motivators and assessment of progress e Responds faster to customer demands e Helps align existing resources within the organization e Allows the organization to assess the overall impact of a change Maintains organizational effectiveness and efficiency by acknowledging the concerns of the staff Increases employees performance Increases customer services Provides a way to anticipate challenges to respond efficiently Helps to contain cost associated with a change Increases return of investment Create an opportunities for the development of best practices, leadership development and team development Key Principles to Effectively Manage Change The application of these change principles can guide huge time-intensive change such as implementing electronic health records as well as less intense yet continuous change such as adapting to new versions to tried and true software. i , 5

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The Administration of Nursing Services Transparency .One of the most powerful ways of initiating any changes is to be totally transparent with all who are involve in the process. Openness, being informative and involving teams and individuals in the process right from the start are critical for raising the energy and know-how needed to move a change through to completion. Agency. A skilled leader knows how to tap the strength of those they work with to ignite a sense of agency, which naturally leads to the desire to act. Setting people at ease, welcoming their ideas and input and input, and creating an atmosphere that sparks cooperative and collegial action are important ways to develop agency for change within an organization. Readiness. Before people can adapt to a change, whether grand, small or continuous, they need to feel ready. Readiness implies the people involved with the change are prepared to take action, to adapt, and to implement the change fully and completely. Adaptation. All change requires flexibility and adaptation from those involved in it. Each person in an organization has a unique capacity for adaptation, and this uniqueness should be kept in mind. However, there are ways that leaders can support them to move to a higher level of adaptation. First and foremost, provide enough time and resources to support the change. These are critical to the adaptive process. Education, support, personnel, allowing room for experiment and trial and error are all significant and empowering ways to promote adaptation in a cohesive and meaningful way. Voice. It is important to create an environment to where all of the people involved feel comfortable about sharing any concerns, questions, confusion and ideas about the change in a receptive manner. Sometimes being heard is all that is needed to move someone from a stance of resistance through to the process of adaptation. Provide safe mechanisms for communication, using a variety of methods including verbal, written, and electronic, in person meetings, brainstorming sessions, networks and suggestion boxes to provide venues that suit the needs of the all involved. Sustenance. To fully empower people in an organization, on-going support, encouragement, educational, dialogue and accessible resources are needed to maintain a high level of sustenance. When people feel supported, they often also feel safe to explore the waters, to try new ideas and are able to stay adaptable. This critical to dealing with the continuing change often present, where every day can bring fresh new challenges and the need to find different ways of doing things. 128 Hospital Nursing Service Administration Manual

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PART II THE MANAGEMENT IN THE DELIVERY OF NURSING CARE SERVICES

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Nursing Process §$ NURSING PROCESS Introduction The Nursing Process is a process by which nurses deliver care to patients, supported by nursing models or philosophy. It was originally an adopted form of problem- solving and is classified as a deductive theory. This is a cyclical, ongoing dynamic, goal directed and client-centered, that can end at any stage if the problem is solved. The nurses’ evaluation of care will lead to changes in the implementation of the care and the patients’ needs are likely to change during their stay in the hospital as their health either improves or deteriorates. It focuses on the patient holistically. e The nursing process is a systematized and circular problem-solving model for planning and delivering nursing care to patients, their families, and groups in a wide variety of settings. This interactive, productive and robust process helps ensure quality, customized and holistic care. e It is a critical thinking five (5) step process that professional nurses use to apply the best available evidence in caregiving and promoting human functions and responses to health and illness (ANA, 2010). It is a vital dynamic blueprint on how to care for patients. A patient-centered care approach is holistic and essential when the nursing process is applied. Purposes of the Process e To identify client’s health status, actual or potential healthcare problems or needs e To establish plans to meet the identified needs and gaps to deliver specific interventions to meet those needs e To provide a framework for critical thinking in which the practice of nursing and its complexities are based e To provide timely and appropriate care to patients e To deliver critical judgement about patient’s clinical situation and individualizing approaches to care (O’ Neil et, al 2011) e To organize, conduct and reflect care in a systematic organized manner e To make inferences about the meaning of a patient responses to health problems or generalize about his or her health functional state of health e To provide goal-directed patient-centered care 131 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Services Benefits of the Nursing Process To the Client e Continuity of care e Prevention of omission and duplication e Individualized care e Increased client participation To the Nurse Job satisfaction Life-long learning Increased self-confidence Facilitates staffing Standards of practice To the Profession Promotes collaboration Helps people to understand what nurses do Steps of the Nursing Process 1. Nursing Assessment ts 2 Nn Nursing Diagnosis Nursing Planning Nursing implementation Nursing Evaluation and Outcome Identification Nursing Assessment It involves the collection of information from the patient and their family/carers concerning their condition and perceived problems. Hamilton and Price (2013) stated that this is the cornerstone in establishing the needs of the patient and if done well, the nursing process will be a success. Information gathered can be either subjective or objective, and primary or secondary (Kozier et al, 2008). Subjective information is what the patient tells you, how they are feeling, levels and sensation of pain. Objective information is that which can be measured such as blood pressure or weight. Primary information is that which is gained from the patients themselves whereas secondary data is information from other sources, such as family members. Observations are taken to gain a baseline and again to identify anything abnormal which may need urgent intervention. Once all the information are collected it can be documented and sorted (Merlin-Johansson, 2017). 132 Hospital Nursing Service Administration Manual

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Nursing Process Activities include: e Establishing the database (nursing history, physical assessment, review of the patient/ client’s records and nursing literature and consultation with patient/client’s support persons and health care professionals) e Continuously updating the database e Validating data e Communicating data Ii. Nursing Diagnosis The nursing diagnosis is the nurse’s clinical judgement about the patient’s response to actual potential health condition or needs. The information gained from the assessment is used to identify actual and potential problems, as well as strengths. (Yildirimand Ozkahraman, 2011). Strengths might be self-caring abilities or independence in certain areas or prior knowledge or experience of the illness. Actual problems are those that come directly out of the assessment, for example pain from a fracture. Potential problems are those that arise from out of the problem, for example the risk of developing a pressure sore if confined to bed (Hogston, 2011). Activities include: e Interpreting and analyzing patient/ client data e Identifying patient/ client strength and health problems e Formulating and validating nursing diagnosis e Developing a prioritized list of nursing diagnosis Ill. Nursing Planning and Outcome Identification It is where interventions are identified to reduce, resolve or prevent the patient’s problems while supporting the patient’s strengths in an organized goal-directed way (Kozier et al, 2008). Care needs to be prioritized on the needs of the patient and the seriousness of the problems identified. Hogston (2011) identifies two (2) steps in the planning stage: e setting goals and e identifying actions. SMART short and long term goals should be identified which are Specific, Measurable, Achievable, Realistic, and Timely. These are all done in collaboration with the patient.(Hamilton and Price, 2013). In action planning, the actual care that is going to be implemented needs to be clearlystated. Hogston (2011) advises using the REEPIG Criteria to ensure that care is of highest standards. R-ealistic E-xplicity stated E-videnced—based P-rioritized 133 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Services I-involve both the patient and other members of the multidisciplinary team who are going to be involved in implementing the care G-oal-centered Activities include: e Establishing priorities e Writing goals and developing evaluative strategies e Selecting nursing measures e Communicating the plan of nursing care IV. Nursing Implementation This is where the care is delivered. As each new member of the caring team comes on duty, they need to re-assess if the care being delivered is still appropriate. Activities Include: e Carrying out the plan of care e Continuing data collection and modifying the plan of care as needed e Documenting the care given V. Nursing Evaluation The most important part of the nursing process after the assessment is done is to evaluate whether the care given achieved the desired result. This should occur constantly as care is being implemented. Evaluation at the end of a course of treatment involves re-assessment of all the plan of care to determine if the expected outcomes have been achieved (Yildirin and Ozkahraman, 2011). Hogston (2011:16) also states the evaluation is “an opportunity to review the entire process and determine whether the assessment was accurate and complete, the diagnosis correct, the goals realistic and the prescribed actions appropriate.” With evaluation the whole process starts again. Activities Include: e Measuring how well the client has achieved the desired goals e Identifying factors that contributed to the client’s success or failure e Modifying the plan of care (if indicated) 134 Hospital Nursing Service Administration Manual

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Nursing Process ds 2: ASSESSMENT PLANNING 1 THE Collection | Making INTERVENTION of : the & Data : Nursing ‘ Diagnosis ' cliént/pgtient 4. 3 EVALUATION S oe IMPLEMENTATION OF INTERVENTION INTERVENTION Figure 8.1 The Nursing Process The Nursing Process functions as a systematic guide to client-centered care with sequential steps. These are assessment, planning, implementation and evaluation. Assessment is the first step and involves critical thinking skills and data collection. Planning stage is where goals and outcomes are formulated that directly impact patient care base on guideline. Implementation step involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. Evaluation, the final step of the nursing process, is vital to a positive patient outcome. Hospital Nursing Service Administration Manual 135

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Modalities of Care Q MODALITIES OF CARE Introduction Nursing Modalities are ways where care is organized and delivered to patients. They have to do with arranging staff members and assigning patients. Care delivery methods take into account the total number of patients and tasks needed to be accomplished, as well as how many nurses are available. Most importantly, they are concerned with meeting patient’s needs and continuity of care. However, patients’ needs go beyond mere health care but encompass social, cultural, psychological, and even ethnic considerations. Moreover, emphasis on long-term goals of ensuring the professional and technical skills enhancement of the employees shall be included in the use of nursing care models. There is no single modality of care that is effective to all hospital settings. Each modality has its advantage and disadvantages. The appropriate care delivery model is the one that maximizes existing resources while meeting the objectives of patients care functions. A health institution may use multiple modalities of care to be responsive to the present situation and health care needs. A mix of modalities of care may also be necessary in the evolving health environment. The choice of appropriate nursing care modality is left to the judgment of the nursing managers. Each nursing professional plays a critical role in patient care and the way in which patients experience their health care. Nursing care models vary in administration and scope. While some provide quality care for large numbers of patients, others focus on serving the needs of individuals. Nursing care models are fluid, allowing each hospital, clinic or private practice to devise a method to serve patients. Methods of Modalities of Care Four basic methods of modalities of care e functional, e total care nursing, e primary nursing and e team nursing New care models are actually variants of the four basic care models. 137 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Functional Nursing It is a task or activity-oriented system of care that concentrates on duties. The nurse coordinates care for an entire unit or team. He/She performs as medication nurse, an Intravenous nurse, documentation or charge nurse. For each task that needs to be done, one nurse handles it for all the patients. Nurse IIT Nurse II Nurse Nurse Nurse 5 ace Nurse Attendants ; pecific functions Vital signs Medication Assessm ents Intravenous Nurse ; and roles in the Hegais eel Treatments Cate Plans Administration Documentation OB-GYNE Com- related assigned plex and other activities related areas Assigned Patient Group Figure 9.1 Functional Nursing Care Delivery Model Advantages of Functional Nursing e Itis efficient and the best system that can be used when confronted with large number of load and a shortage of nurses. e Implements classic scientific management, which emphasizes efficiency, division of labor and rigid control. e Little confusion about roles and duties. e Itis less costly and requires few registered nurses. Disadvantages of Functional Nursing e Care tends to be fragmented and depersonalized e Less oriented to individualized and holistic client care and more oriented to task accomplishment e Registered Nurse keeps busy with managerial and non-nursing duties and nursing attendants deliver the majority of patient care. © Does not encourage patient-staff satisfaction. © Clients felt that they could not identify who was their nurse caretaker. e Routinized patient care for patients with similar needs may meet those needs more consistently than other systems and some staff nurses maybe satisfied by doing repetitious jobs well. 138 Hospital Nursing Service Administration Manual

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Modalities of Care Total Patient Care or Case Nursing Total patient care is a case method for organizing nursing care in which nurses are responsible for the total care of a client but only for the hours, in which that specific nurse is present. Equally important consideration in the choice of modalities of care is the patient care needs. Level 4 clients, total care nursing is most effective where one nurse is assigned to one patient for the delivery of total care. The nurse plans, coordinates, implements, evaluates and documents the nursing care she has given during her shift. His or her entry point is anytime of the patient’s illness. The one-on-one pattern is a common assignment for private duty nurses, for nurses in special care units such as the critical care units or that in isolation, and for nursing students. As always is the case, government hospitals with limited financial capacity cannot sustain a one on one total care nursing. For patients needing such a care modality, an arrangement is made to avail of the services of a private duty nurses with added cost to the clients. Nurse Nurse Nurse 8-hour shift 8-hour shift 8-hour shift Patient Care and Other Services Figure 9.2 Total Patient Care Nursing Delivery Total Patient Care means that a Professional Nurse is accountable to provide and coordinate the care of a patient or groups of patients assigned to her/him during working hours. Advantages of Total Patient Care e Focuses on the entire episode of illness e Emphasizes achievement of outcome e Incorporates manage care 139 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Disadvantages of Total Patient Care e Takes time and effort to coordinate to other members of the health team. e Limits communication and continuity of care for the client over time. e Restricts job mobility and nurses are limited to perform other tasks related to Nursing practice. Primary Nursing It is an approach to which a nurse has responsibility and accountability for the continuous care of specific clients from hospital admission to discharge. It is also a modality though not to be cost-effective because of the exclusive use of individualized holistic nursing care. Nurse III Nurse II F an and i other members of thehealth Po----------- | care team | Prim ary Nurse Nurse Reliever 24-hour responsibil- ity for planning di- Provide care when recting & evaluating prim ary nurse is off patient care duty Patient Figure 9.3 Primary Nursing Care Primary Nursing is a method of nursing practice which emphasizes continuity of care by having one nurse provides complete care for a small group of inpatients within a nursing unit of a hospital. 140 Hospital Nursing Service Administration Manual

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Modalities of Care Advantages of Primary Nursing e Provides for increased autonomy on the part of the nurse, thus,increasing motivation, responsibility and accountability. e Assures more continuity of care as a primary nurse gives or directs care throughout hospitalization. e Makes available the increased knowledge of the patient’s psychosocial and physical needs. e Leads to increased rapport and trust between the nurse and the patient that will allow formation of therapeutic relationship. e Improves communication of information to the physician. Disadvantages of Primary Nursing e Confines nurses’ competencies to a limited number of patients. Other patients cannot benefit, and if a patient has a nurse who is not capable, the patient maybe worse off than if cared for by a numerous people some of whom might meet the patient’s needs. e Problems may occur if the other nurse changes the care plan without discussing the reasons with the primary nurse. e Problems in the implementation of primary nursing have included the wide variation in its operationalization and implementation. e Primary nurse autonomy under cost containment pressure, in all RN staff is difficult to justify. e Total accountability may create burn out, and a poorly prepared RN may feel threatened by primary nursing Team Nursing It is a decentralized system of care in which a nurse leads the group in providing the needs of patients/clients through participative effort. Through team plan, the contributions of all team members are recognized and priority is given to strengthening their weaknesses. These are carried out through conferences, meetings and other forums. The team nursing utilizes type of care modality effectively across all levels of care (Level 1, 2, 3 and 4 patients) so long as the nurse patient ratio is decreased as the level of care is increased. Levels of Care Nurse Patient Ratio Remarks 1 maximum of 1: 12 is acceptable 2 maximum of 1:12 is manageable ‘ , can be efficiently 3 SECS "ust handled by a single nurse (Critical Care) Is just within the capacity of an maximum of 1:3 (all ICU’s, : d experienced nurse to provide safe 4 PACU, ER) nursing practice (Specialized Care) Non bedded 2:1 (2 nurses per room or performing unit)example Operating Room/ procedures Delivery Room 141 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Nurse Supervisor Senior Nurse f Team Leaders . Operating OB-Gyne Emergency Team Critical Care and Clinical Care cae and Room Team DR Team Specialized Care Team rograms Team Team Assigned Patient Group Figure 9.4 Team Nursing Care The team nursing model of care involves pairing nurses who works as a team to deliver patient care. Advantages of Team Nursing Motivates full participation among team members towards quality and safe care. Maximizes staff capabilities. Sets goal and priorities for patient care; and centralizes information through the use of a Kardex. Directs the plan of care through conferences and other related activities like Nursing audits, etc. Disadvantages of Team Nursing Does many tasks for a limited number of patients instead of a single task for a e large number of patients, thus, increases likelihood of committing errors. e Takes time to coordinate delegated work. e Limits application of holistic Nursing Care resulting to incomprehensive routine care 142 Hospital Nursing Service Administration Manual

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Quality Management 10 Quatity MANAGEMENT Introduction The Department of Health (DOH) issued Administrative Order No. 2006- 002 s. January 23, 2006,“Establishment of the Continuing Quality Improvement (CQI) Program and Committee in DOH Hospitals,” that was reiterated by the Philippine Health Insurance Corporation (PHIC) through their issuance of Philippine Health Circular No. 12 s. 2006,“Requirement for a Continuous Quality Improvement Program in Accreditation of Hospitals.” The said circular required all accredited hospitals to have a CQI as described in Part III of the Benchbook. Congruent with the requirements of hospital licensure and the intent of Department Order Nos. 310-J s. 2001 and 172-C s. 2003 on “The Creation of the DOH Steering Committee and Technical Working Group for the Establishment of CQI Program for the Health Regulation Cluster and DOH Hospitals” and its amendment respectively, to consistently deliver and continuously improve the quality of health care to our people, there is a necd to institutionalize and establish the Continuing Quality Improvement. Quality Assurance (QA) Program has been the framework of the different Manuals of Standards published by DOH through the Hospital Operations and Management Service in 1994. Its objective then was to provide guidelines for the hospitals to plan and systematize the necessary actions for the provision of quality service. The QA mechanism has been evolving since its inception. It has develops from a prescriptive mechanism into a more facility-oriented system. It is the process through which the level of quality is defined, pursued, mechanisms/systems and structure within the organization. When the idea of CQI becomes a management philosophy permeating every aspect of the hospital, it becomes the Total Quality Management (TQM). “Implementing a TQM Program involves three steps: First, awareness of the management of the importance of quality improvement; Second, mobilization of the quality improvement team; Third, launching of the organization-wide improvement activities” (Kelada, 2006). Total Quality Management (TQM) can offer using practical solutions to the “best for less” dilemma when specifically adapted to the needs of the nursing profession and individual nursing service departments. TQM philosophy and its principles presents strategies that may be used by nurse executives interested in integrating TQM into 143 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care their nursing management systems, and discusses specific guidelines for successful implementation of TQM within any nursing department. The National Health Insurance Act of 1955(R.A. 7875) supports the provision of the Constitution. In order to be accredited to participate in the National Health Insurance Program, health care providers, including hospitals, are required to establish the Quality Assurance Program. The common measure in health care delivery services today, from the clinical point of view, is the quality of care provided. Quality serves as the balance that demonstrates professional commitment to patient care. DOH Administrative Order No. 2010-0007 instituted the guidelines for the National Framework for Quality in Health. As such, an organization has to come up with Continuous Quality Improvement (CQI) otherwise known as the Quality Management Process, which encourages all healthcare team-members to continuously ask the questions: “How are we doing?.” and “Can we do it better?” thus, enhancing the organizational services and ensuring public trust in the healthcare delivery system. Definition of Terms Quality is the degree of excellence. Doing the right things right. Quality Care is the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with the current professional knowledge. Quality Assurance is a process of evaluation that is applied to the health care system and the provision of health care services by health workers. It promotes collegial and sharing relationships among workers instead of a feeling of threat when observed and evaluated. Quality Improvement program in an organization is the umbrella program that extends the many areas for the purpose of accountability to the clients and the payor. The program is a continuous, on-going measurement and evaluation process that includes structure, process and outcome. Quality Improvement Plans (QIP) is a plan of action outlining the things we can do differently at achieve results for our responsibility areas to continuously improve the delivery of healthcare services and likewise comply with stakeholder’s standards and requirements. Is a plan to continuously monitor, analyze and improve the health facilities managerial systems and processes, must be well organized and have a clear leadership role to achieve maximum benefits. 144 Hospital Nursing Service Administration Manual

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Quality Management Indicators are valid and reliable quantitative measures of structure, process and outcome that are related to one or more dimensions of performance. Clinical indicators relate to clients, and may be focused on service, practice or governance. Sentinel Event indicators measure a low-volume but serious, undesirable and often avoidable processes or outcomes such as falls and medication errors. Benchmarking is a tool to assist in quality of care decision-making. It is a continuous process of measuring what exists against the best in for the industry best practices. Best Practice is a service, function or process that has been fine-tuned, improved and implemented to produce superior outcomes. Best practices are activities that can lead to establishing benchmarks. Quality Management (QM) is defined as a formalized system that documents the structure, responsibilities and procedures required to achieve and deliver a quality product. It describes the standards, quality practices, resources and processes pertinent to an organization. Total Quality Management (TQM) is a way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service. All systems are evaluated and improved. It aims to reduce waste and cost of poor quality. It is a structured system for involving an entire organization in a continuous quality improvement process targeted to meet and exceed customers’ expectations. Effectiveness of a particular nursing intervention can be identified by the extent to which desired outcomes are obtained through the use of that intervention. Measures of effectiveness should reflect whether the organization, group or process achieve the desired results. Efficiency of a particular nursing intervention can be determined by computing the cost-benefit ratio on the relationship between the monetary value of the resources expanded and the value of the results achieved. Efficiency is concerned with the percentage of resources actually used over the resources planned to be used. Continuous Quality Improvement (CQJ) is a process through which the level of quality is defined, pursued, achieved and continuously improved through the establishment of formal mechanism/systems and structures within the organization. Continuous quality improvement describes the overall effort of the hospital organization to achieve the most effective care with the available resources and without compromising quality. 145 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Continual Improvement is an ongoing effort to improve products, services or processes. It seeks incremental improvement overtime or breakthrough. Rapid-Cycle Testing is a way to conduct Plan-Do-Study-Act (PDSA) Cycles. In a PDSA Cycle, the goal is to test a particular change on a small scale, learn what you can, and get better in the next application. The change team compares the results of each change cycle to pre-test measurements (baseline data). Risk Management is the forecasting and evaluation of various risks and hazards with the identification of the procedures to avoid or minimize its impact Principles of Total Quality Management

1. Leadership. Leaders establish unity of purpose and direction of the organization. They should create and maintain the internal environment in which people can become fully involved in achieving the organization’s objectives.
2. Customer Focus. Organizations depend on their customers and therefore should understand current and future customer needs, meet customer requirements and strive to exceed customer expectations.
3. Process Approach. A desired result is achieved more efficiently when related resources and activities are managed as a process.
4. Involvement of People. People at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit.
5. System Approach. Identifying. understanding. and managing a system of interrelated processes for a given objective improve the organizations effectiveness and efficiency.
6. Continuous Improvement. Continual improvement should be a permanent objective of the organizations.
7. Factual Approach to decision making. Effective decisions are based on the analysis of data and information.
8. Mutual Beneficial Supplier Relationships .An organization and its suppliers are interdependent and mutually beneficial relationship enhances the ability of both to create value. Strategies in Total Quality Management With this in mind, we have highlighted 4 key areas within organizations where a comprehensive quality management strategy could help:

Internal Processes A comprehensive quality management program is based on real evidence from within your organization. With the key aim being to diagnose the possible reasons why things can go wrong, having a detailed quality management plan in place shines the spotlight on internal processes in an attempt to debug the root cause of the issues. 146 Hospital Nursing Service Administration Manual

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Quality Management 2. Cost Reduction Cost reduction, particularly in large-scale organizations, is often one of the most effective fixes for organizational performance improvement. Laser-targeting your attention toward inefficiencies in the production and development process can eventually lead to long-term fixed-cost reduction. 3. Environmental Effects In today’s business environment, an environmentally-conscious approach is no longer a choice, it’s a necessity. Quality management strategies can help you to analyze your organization’s effect on the environment, whilst focusing on processes that can minimize your environmental impact. This helps you to identify operational inefficiencies that may not have previously been noted. 4. Regulatory Compliance Regulatory compliance can be built into your quality management strategy to ensure all requirements are dealt with proactively. Taking a forward-thinking approach by implementing a quality management strategy will help your organization move forward with confidence in a competitive environment. Our quality management certifications can help lead you to success. Quality Improvement Plans (QIP) It is an organization's framework for developing and improving processes. It includes the direction, timeline, activities, and assessment measures of quality and quality improvement within the organization. With these plans, every hospital is expected to set targets aimed at making improvements in the areas of Safety, Effectiveness, Access and Patient-Centeredness. The aim of a QIP is to help providers self-assess their performance in delivering quality education and care, and to plan future improvements. The QIP also helps regulatory authorities with assessing the quality of the service(See Appendix R, Sample Quality Improvement Plan). Purposes of Quality Improvement Plan (QIP) e To determine what needs to be done to continuously improve what went well and what went wrong, by who, when, where and how will things be done. e To maximize the effectiveness of an organization by determining goals, strategies, activities and resources for achieving them in accordance with the appropriate objectives. 147 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Things to include: A QIP must: Include an assessment of the programs and practices at the service against the National Quality Standard and National Regulations Identify areas for improvement Include a statement about the service’s philosophy. The following provides a step-by-step guide on how to develop a QIP: 1. Use organizational-level data to identify your current performance and/or baseline for the priority indicators. (If no baseline exists, note this in your QIP, and begin gathering the data you need.) Organizations are expected to review the priority indicators for their sector and determine which are relevant for their organization. To support this process, your organization should review its current performance against provincial benchmarks/theoretical best for all priority indicators. If your organization elects not to include a priority indicator in the QIP (for example, because performance already meets or exceeds the benchmark/ theoretical best), then this should be documented in the comments section of the QIP Work plan. Use the guidance provided to create a plan to address each of the system level priorities you identified for improvement. A plan includes setting a target, identifying change ideas to be tested, methods and process measures, as per the QIP Work plan. Ensure you complete the Narrative to use to communicate these priorities to your communities and staff. Sign-off: Once the QIP has been approved by the Board, the Quality Committee (if applicable) and key senior leadership, those involved need to “sion off’ on the QIP. This is an important component to help demonstrate the shared accountabilities and responsibilities for the QIP at the governance, clinical, and administrative levels. Principles of Quality Improvement When quality is considered from the Institute of Medicine (IOM) perspective, then an organization’s current system is defined as how things are done now, whereas healthcare performance is defined by an organization’s efficiency and outcome of care, and level of patient satisfaction. Quality is directly linked to an organization’s service delivery approach or underlying systems of care. To achieve a different level of performance (i.e., results) and improve quality, an organization’s current system needs to change. While each QI program may appear different, a successful program always incorporates the following four key principles: QI work as systems and processes Focus on patients Focus on being part of the team Focus on use of the data 148 Hospital Nursing Service Administration Manual

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Quality Management Work as Systems and Processes To make improvements, an organization needs to understand its own delivery system and key processes. The concepts behind the QI approaches in this toolkit recognize that both resources (inputs) and activities carried out (processes) are addressed together to ensure or improve quality of care (outputs/outcomes). RESOURCES ACTIVITIES RESULTS UNPUTS) {PROCESSES} (OUTPUTS OR OUTCOMES) People

2 Health services | Gelvered eae : :

Change in health | Matenals{ie. ee SS 2 é vaccine) FE i. Whatisdone

behavior information infrastructure 2. How ft is done | Change in health - Technoingy : ase : a / Patient . Satistaction Figure 10.1 Inputs, Processes and Outputs/Outcomes(Source: Donabedian, 1980) Figure 10.1 shows how a health care delivery system consists of resources. activities. and results; these key components are also called inputs, processes, and outputs/outcomes: 1 Quality Improvement Source: Donabedian (1980) Figure 1.1: Inputs, Processes and Outputs/Outcomes. Activities or processes within a health care organization contain two major components: 1) what is done (what care is provided), and 2) how it is done (when, where, and by whom care is delivered). Improvement can be achieved by addressing either component; however, the greatest impact for QI is when both are addressed at the same time. Focus on Patients An important measure of quality is the extent to which patients’ needs and expectations are met. Services that are designed to meet the needs and expectations of patients and their community include: e Systems that affect patient access Care provision that is evidence-based Patient safety Support for patient engagement Coordination of care with other parts of the larger health care system Cultural competence, including assessing health literacy of patients, patient- centered communication, and linguistically-appropriate care 149 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Focus on Being Part of the Team QI is a team process. Under the right circumstances, a team harnesses the knowledge, skills, experience, and perspectives of different individuals within the team to make lasting improvements. A team approach is most effective when: The process or system is complex No one person in an organization knows all the dimensions of an issue The process involves more than one discipline or work area Solutions require creativity Staff commitment and buy-in are needed eoeoeeee@ Focus on Use of the Data Data is the cornerstone of QI. It is used to describe how well current systems are working; what happens when changes are applied; and to document successful performance. Using data: e Separates what is thought to be happening from what is really happening Establishes a baseline (Starting with a low score is acceptable) Reduces placement of ineffective solutions Allows monitoring of procedural changes to ensure that improvements are sustained Indicates whether changes lead to improvements e Allows comparisons of performance across sites The Role of Organizational Leadership The leader's role in promoting and developing QI begins with creating and sustaining a personal and organizational focus on the needs of internal and external customers. Through actions, a leader demonstrates a clear commitment to the organizational mission, values, goals, and expectations that promote quality and performance excellence. The customer-oriented mission, vision, values, and goals of an organization are best integrated into all aspects of management through effective leadership. An organization that experiences success in the development and implementation of its QI program understands that the organization's chief officer or senior leader creates energy, synergy, and focused leadership for the QI program. Under his or her leadership, all other managers or leaders work together to: e Set the direction for QI by creating a strong patient focus e Create clear statements that define the organization's mission and values, and identify operational objectives, and short- and long-term expectations e Demonstrate continuous commitment to achieving the organization's QI goals 150 Hospital Nursing Service Administration Manual

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Quality Management Quality Improvement Program (QI Program) Involves systematic activities that are organized and implemented by an organization to monitor, assess, and improve its quality of healthcare. The activities are cyclical, so that an organization continues to seek higher levels of performance to optimize its care for the patients it serves, while striving for continuous improvement. A QI program typically envelops all QI activities within an organization. Clinically- related QI initiatives and activities to improve an organization’s operations and finance are common examples. A QI program in a healthcare organization often begins with leadership considering these questions: e Why is a QI program important to an organization? e What does an organization need to know as it develops a QI program? e How does an organization start its development of a QI program? e How do QI processes work to support the success of the QI program? Nursing Quality Improvement Quality Improvement nursing strives to support clinical practices for optimal patient care outcomes. It is within this area that a nurse identifies, monitors, and makes recommendations for quality nursing care. Quality improvement nursing involves determination to meet patients’ needs and exceed expectations of care and service. A structured process is used to continually identify and improve all of the aspects of service and care. Purposes e Enhances patient care through systematic assessment and improvement of the quality and appropriateness of care rendered by the Nursing Service personnel. e Improves patient services through evaluation of clinical and operational performance which measures are integrated in the management processes. e Achieves the triple aims of health care such as improving the experience of patient care, improving population health, and cost effectiveness of health care and services. e Utilizes sound effectiveness of services for better health outcomes, responsive service delivery network, financial risk protection, performance and accountability Goals and Objectives The primary goal of the Quality Improvement Program is the ongoing improvement of the delivery, quality, efficiency, and outcome of patient care services. This is accomplished through a systematic examination of information provided through ongoing monitoring, evaluation, and improvement activities. All quality activities are done in accordance with standards of professional health care practices, regulatory and licensing agencies and support the overall hospital’s mission and strategic plans. 151 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Establishes an ongoing improvement of the delivery, quality, efficiency and outcome of patient care services through a systematic examination of information provided through ongoing monitoring, evaluation, and improvement activities; Provides ongoing nursing staff education related to departmental QI indicators and results including related internal and external standards; Improves client satisfaction with nurses efforts to reduce pain; Improves identification of patient at risk for falls; Reduces patient fall occurrences; Reduces utilization of restraints; Initiates appropriate isolation precautions upon identification of established criteria; Promotes patient safety related to medications administration, verbal / telephone orders; Increases efficiency of patient data collection and documentation through automation; Provides continuity of care through documentation of patient education, assessment and teaching; Improves nursing documentation of comprehensive pain assessment when pain is present upon patients’ admission; Identifies factors affecting availability of beds for outside patient’s transfers; and Improves existing and or develops automated management reports to make data collection process more efficient. The Chief Nurse has the authority and direct responsibility for the continuous assessment and improvement of the quality of nursing services, provided it is based on key indicators which measure customer expectations for critical processes, but CQI is everybody’s concern. Scope The Nursing Service Quality Improvement Program encompasses relevant dimensions of performance including those that are high volume, high risk or problem-prone. The scope of patient care services provided by the department includes: e Assessment of patients and monitoring for early recognition of adverse events, complications and errors Planning, implementing, evaluating the nursing care plan Initiating safe and quality care Educating patients and family on health care and related activities essential and contributory to patient’s recovery Ensuring adequate and competent human resource to carry out care and other related activities 152 Hospital Nursing Service Administration Manual

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Quality Management Nursing care is provided on a 24-hour basis to patients from infancy to old age encompassing health care needs all throughout the life span. Nursing care is provided in an organized and systematic process under the direction of a nurse. The nursing process begins with the assessment and recognition of the patient’s priority needs, development and implementation of a plan of care to address those needs, and finally the evaluation of the effectiveness of the plan. Discharge planning, patient teaching, implementation of current nursing standards, and collaboration with interdisciplinary teams are key components of quality nursing care. Key Staff Roles in a OI Program For quality to be effectively managed, individuals and groups in an organization should have a clear understanding of their roles and responsibilities relative to QI. Each staff member has a role in ensuring that QI objectives set by the organization are met. Ideally, all contributions are equally valued on the QI team. Since individuals on the QI team work in fundamentally different ways when doing improvement work compared with actual patient-care delivery, it is important to formalize their roles within the committee. Sample Quality Improvement Program The goal is to deliver safe, high-quality care to patients in all clinical settings. You can use the information in this guide to help improve quality of care across settings and at multiple levels. e Patient Centered Care

Falls and Injuries

Pressure Ulcers

Ventilator Associated Pneumonia (VAP)

Intravascular Catheter-Related Infections

Urinary Catheter-Related Infections

Preventing Other Healthcare Associated Infections e Opportunities for Patient Safety and Quality Improvement

Reducing Medication Errors

Handoffs e Working Conditions and Work Environment for Nurses

Nurse Fatigue and Stress

Nursing Turnover

Teamwork

Nursing Workload and Patient Safety e General Resources on Nursing and Quality of Care Continuous Quality Improvement (CQI) Is a quality management approach that is based on the idea that most processes can be improved and made more efficient? Instead of focusing on the issue only when a problem is inevitable, and a dramatic intervention is necessary, CQI advocates for 153 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care incremental, but regular changes that become a part of organization's day-to-day activities. CQI offers a set of concepts and methods that are applied to the organization's processes. It shifts the attention from the people of an organization to its processes and products, seeking ways to satisfy organization's internal (employees) and external customers. CQI encourages teamwork and utilizes internal knowledge to optimize the processes. Such methods are applied across a variety of industries, from manufacturing to healthcare. This can be achieved through the continuous application of the PLAN, DO, CHECK, and ACT Cycle (PDCA). Continually Improving, in a Methodical Way Also known as PDSA, the "Deming Wheel," and "Shewhart Cycle" The PDCA cycle encourages a commitment to continuous improvement. PDCA / PDSA is an iterative, four-stage approach for continually improving processes, products or services, and for resolving problems. It involves systematically testing possible solutions, assessing the results, and implementing the ones that are shown to work. The PDCA or PDSA Cycle The PDCA cycle helps you to solve problems and implement solutions in a rigorous, methodical way. Follow these four steps to ensure that you get the highest quality results.

1. Plan .First, you need to identify and understand your problem, or the opportunity that you want to take advantage of. Using the first six steps of The Simplex Process can help you to do this, by guiding you through a process of exploring information, defining your problem, generating and screening ideas, and developing an implementation plan. At the final part of this stage, state quantitatively what your expectations are, if the idea is successful and your problem is resolved. You'll return to this in the Check stage. Once you've identified a potential solution, test it with a small-scale pilot project. This will allow you to assess whether your proposed changes achieve the desired outcome, with minimal disruption to the rest of your operation if they have not 154 Hospital Nursing Service Administration Manual

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Quality Management been achieved. For example, you can organize a trial within a department, in a limited geographical area, or with a particular demographic. As you run the pilot project, gather data to show whether the change has worked or not. You'll use this in the next stage. 2. Remember that, in this situation, Do means "try" or "test." It doesn't mean "implement fully," which happens at the Act stage. 3. Check. At this stage, you analyze your pilot project's results against the expectations that you defined in Step 1 to assess whether the idea has worked or not. If it hasn't worked, you return to Step 1. If it has worked, you go on to Step 4. You may decide to try out more changes, and repeat the De and Check phases — don't settle for a less-than-satisfactory solution. Move on to the final phase (Act) only when you're genuinely happy with the trial's outcome. 4. Act. This is where you implement your solution. But remember that PDCA / PDSA is a loop, not a process with a beginning and an end. This means that your improved process or product becomes the new baseline, and you continue to look for ways to make it even better for your organization or customers. When to Use PDCA / PDSA The PDCA / PDSA framework can improve any process or product by breaking it into smaller steps. It is particularly effective for: e Helping to implement Total Quality Management or Six Sigma initiatives, and generally helping to improve processes. e Exploring a range of solutions to problems, and piloting them in a controlled way before selecting one for implementation. e Avoiding wastage of resources by rolling out an ineffective solution on a wide scale. You can use the model in all sorts of business environments, from new product development, project and change management, to product lifecycle and supply chain management. 155 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Quality Improvement in Practice Plan-Do-Study-Act Quality Knowledge — Practice Improvement — Better Outcomes How will | know if the change made What is the a difference? clinical problem that I want to solve What change “ i What do | need to know? need tomake? (e.g. How many patients are affected - “data collection”) What office A Pm systems are j affected? Leg Figure 10.2 Quality Improvement in Practice 156 Hospital Nursing Service Administration Manual

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Quality Management Review Data Inform Patient Care Evaluate and Work Nursing Per- formance Formulate Goals Identify Areas for Improvement Figure 10.3 Quality Improvement in Nursing a

falls finjury ulcer —_ a

res 1 a

health care related VA NN

• staff mix

nurse patient ratio

nursing care hours per patient per day

nursing education Figure 10.4 Nursing Quality Indicators 157 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Roles of Nursing Leaders Tasked with various challenging duties, first, they must continually assess personnel and process performance trends and data. Then, they compare this data against current practices, collect additional information, formulate a plan and provide valuable feedback and improvement recommendations to health care organization executives. Part of this will involve soliciting and surveying patients, employees and anonymous members of the public. Second, must oversee and promote compliance with standards. Consequently, they must prepare and submit reports. Third, they design and execute training programs designed to enhance health care professionals’ knowledge of risk management and quality improvement, they must prepare formal responses, quality assessments and risk management reports for hospital administration, regulatory agencies and other official parties. Reporting The Chief Nurse or designate is responsible for routine reporting to the CQI Committee on key quality indicators and their impact on improvement, or potential action plan for unresolved issues. In turn, reporting advances upward through the management structure until significant quality issues are adequately addressed. Proposals formally supported by CQI Teams can be forwarded based on departmental quality efforts which identified the needs for a broader multidisciplinary approach. Confidentiality To protect patient care and provider’s rights, quality improvement information should be accessible to Authorized Personnel Only. Nursing Service Audit is a critical analysis and systematic review of nursing and patient’s health records, physical facilities, and allied personnel involved in patient care for the purpose of evaluation, verification and improvement of services based on tools and standards. Nursing Audit Committee is created and composed of a representative from all levels of the nursing staff: a member of the Training Staff, Supervising Nurse, Senior Nurse and a Staff Nurse. Compositions may vary in other hospitals. In smaller hospitals, the Chief Nurse or his/her Assistant may be a member of this committee. Audit Committee consists of members including senior nurses as members to do nursing audit. This committee should comprised of a minimum of five members who are interested in quality assurance, are clinically competent, and are able to work together in a group. 158 Hospital Nursing Service Administration Manual

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Quality Management The Nursing Audit team utilizes the developed process or outcome criteria to evaluate nursing care. Roles e Encourages followers to be actively involved in the quality control process. e Clearly communicates standards of care to subordinates. e Encourages the setting of high standards to maximize quality instead of setting minimum safety standards. Implements quality control proactively instead reactively. Uses control as a method of detraining why goals were not met. Is positively-active in communicating quality control finding. Acts as a role model for followers in accepting responsibility and accountability for nursing action. Functions e Establishes clear-cut, measurable standards of care, in conjunction with other personnel in the organization, and determines the most appropriate methods for measuring if those standards have been met. e Selects and uses process, outcome and structure and its appropriately as quality control tools. e Assesses appropriate sources of information in data gathering for quality control tools. e Determines discrepancies between care provided and unit standards and seeks further information regarding why standards were not met. e Uses quality control findings as a measure of employee performance and rewards, coaches, counsels or disciplines employees accordingly. e Keeps abreast of current government and licensing regulations that affect quality control. Methods of Nursing Audits Patient Care Audits. Patient care audits may be concurrent or retrospective. A Concurrent Audit is one in which patient care is observed and evaluated as it is given through: e a review of the patient’s charts while the patients are still confined in the hospital; e observation of the staff as patient care is given; e Inspection of patients and/or observation of the effects of patient care where the focus is on the patient (done during rounds or patient’s interview). A Retrospective Audit is an in- depth assessment of quality of care after the patient has been discharged and uses the charts and other documented information as sources of data 159 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Peer Review The evaluation of care by one or more people of similar competence to the producers of work to maintain standards of quality, improve performance and provide credibility. Utilization of Results The Nursing Staff in the unit is given a feedback on the results of the quality assurance study. This may be oral or written and is directed to the staff who administers the care by their immediate supervisors. Findings are used for improvement of services towards positive organizational output. Quality Circle The Quality Circle is composed of trained, organized and structured groups of hospital employees within the nursing division who share common work interests and goal. The Quality Circle are the ones responsible in identifying, analyzing, and solving other work-related problems. Objectives e Reduces errors and enhances quality e Inspires more effective teamwork e Promotes involvement at all levels e Increases employee motivation e Increases problem-solving capability Builds an attitude of problem prevention e Improves agency communication e Develops harmonious worker-manager relationship e Promotes personal and leadership development e Develops greater safety awareness. Quality Assurance Quality assurance is a way of preventing mistakes and defects in manufactured products and avoiding problems when delivering products or services to customers; which ISO 9000 defines as "part of quality management focused on providing confidence that quality requirements will be fulfilled". Components of Quality Assurance Process I. Assignment of responsibility. Overall responsibility in a given department is assigned to the Director or Chairperson. In turn, each nursing unit forms a Quality Circle composed of a Chairman and members who share the responsibilities of conducting QA programs such as monitoring and evaluation activities. 160 Hospital Nursing Service Administration Manual

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Quality Management II. Delineation of scope of care. This component identifies the diagnostic, Il. IV. therapeutic and other services provided; the type of patients served, their conditions and diagnoses; the treatments or activities performed; and the types of practitioners providing care (nurses, nursing attendants, other members of the health team). Identification of important aspects of care. This includes services that are most important to and have the greatest impact on patient care. Priority is given to the following: e Patient care that is frequent and involves a large number of patients; e Patients who are at risk of serious consequences or are deprived of substantial benefit if care is not provided correctly; e Aspects of patient care that are known by experience to present problems for staff and/or the patients; and e High-volume, high-risk, or problem-prone aspects of patient care which should have the highest priority for monitoring and evaluation. Identification of indicators related to aspects of care. Such indicators are clinical, objective and measurable variables for monitoring the quality and appropriateness of a particular aspect of patient care. They refer to (a) structure — inputs into patient care such as resources, equipment, numbers and qualifications of staff; (b) process — functions carried out by nurses; and (c) outcome — the results of treatment on patients and adverse events. Indicators can be developed based on knowledge and experience, standards of care, organizational and departmental policies and procedures, rules and regulations, job descriptions, and criteria set by the agencies. Hospital-wide indicators can be used by more than one department for documenting undesired occurrences or problem areas such as medication errors and patient falls. Common Quality Assessment Indicators e Accidental injury to the patient Errors in administration of medication or treatment Adverse effects of a treatment, procedure or medication Loss of or damage to personal belongings Stage I and above decubitus ulcer Intravenous infiltration Unavailability of personnel or equipment Malfunction or breakdown of equipment or medical devices Escape of patient Cardiac or respiratory arrests Wound dehiscence Unscheduled admission or transfer to the intensive care unit Hospital-acquired infection 161 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Neurological defects not found upon admission Wrong procedure and/or procedure performed on wrong patient Unplanned return to the operating room during the same admission Any other occurrence not consistent with established clinical practice V. Establishment of a threshold for evaluation. A level of compliance or performance is decided upon over a period of time. For example, the Nursing Division may set the standard for a Nursing Audit of Patients’ charts at 95 percent, as an acceptable threshold for the indicator “audited charts shall have complied with standards in documentation.” VI. Collection and organization of data. The staff members who collect, organize and analyze the data are pre-selected. Sources of data collection are medical records, patient questionnaires, employee’s incident reports on injuries, and observations of employees and patients among others. VIi. Evaluation of care. Analysis of data collected indicates trends and patterns of the problem being studied. Peer review is undertaken when there is a need for an in-depth evaluation of the patient care rendered. VILL. Action to solve identified problem. When a problem has been identified, an In-depth review is done to determine the probable cause and courses of action to be undertaken. Causes are divided into (a) knowledge barriers; (b) behavior problems; and (c) system or communication problems. Corrective actions should state (a) what the problem is; (b) who or what is expected to change; (c) what will be done to implement the change; (d) when the change is expected; and (e) when the situation will be evaluated to see if there is an improvement. Example: Matrix Quality Improvement Activities QI Activity Assessment Focus Assessment Procedure Process and outcome of | Screening Audit administrative or Provider-or service aspect-specific clinical care service document review Utilization Review Process Routine indicator monitoring or screening Provider-specific audit Complaints analysis Input, Process and Outcome Document review Primary data collection Routine Event monitoring Expanded incident | Process and Outcome Document review monitoring Primary data collection Mortality and Process and Outcome | Screening morbidity audit Conference discussion 162 Hospital Nursing Service Administration Manual

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Quality Management QI Activity Assessment Focus Assessment Procedure Sentinel event Input, Process and Routine Event monitoring monitoring Outcome Document review Primary data collection Credential and Input Document review clinical privileging Clinical pathway Causes of variance Pathway review IX. Assessment of the actions done and improvement of documents. Evaluation determines whether the patient care has improved or a solution to the problems has been found. If not, a new plan of action is made and implemented. Monitoring and evaluation should be continuous to ensure resolution and improve patient care. Documentation is needed as a legal record of care, to show the patient’s progress and to determine the quality of care being given. Communication of relevant information to the organization-wide CQI program. Findings can be used to improve orientation, focus on service, continuing education, budget staff, equipment, and assignment of staff. They can also be used to modify or add policies and procedures and appraise staff performances. Seven (7) Basic Quality Tools: NDOBWNe . Flow Chart . Histogram . Cause-and-Effect Diagram . Check Sheet . Scatter Diagram . Control Charts . Pareto Charts Flow charts are one of the best process improvement tools you can use to analyze a series of events. They map out these events to illustrate a complex process in order to find any commonalities among the events. They’re also one of the most common methods of creating a workflow diagram. Flow charts can be used in any field to break down complex processes in a way that is easy to understand. Then, you can go through the business processes one by one, identifying areas for improvement. 163 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care y Fill-up RIS form Nurse Supervisor, Team Leader. Chief Nurse NO Approved vES Rotating Supervisor Submit RIS form to MMS Staff Receive oxygen from Oxygen transporter Nurse, Nursing Attendant, Oxygen Transporter Aften END Histogram: A histogram is a chart with different columns. These columns represent the distribution by the mean. If the histogram is normal then the graph will have a bell-shaped curve. If it is abnormal, it can take different shapes based on the condition of the distribution. Histograms are used to measure one variable against another and should always have a minimum of two variables. 164 Hospital Nursing Service Administration Manual

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Quality Management If it is abnormal, it can take different shapes based on the condition of the distribution. Histograms are used to measure one thing against another and should always have a minimum of two variables. Heights of Black Cherry Trees 10 Frequency I T T T T T 1 60 65 70 75 80 85 90 Height (feet) Check Sheet is a form (document) used to collect data in real time at the location where the data is generated. The data it captures can be quantitative or qualitative. When the information is quantitative, the check sheet is sometimes called a tally sheet. System Complaints Source Monday | Tuesday Wednesday|Thursday| Friday [Saturday Sunday Total Email i l | I | 1, 2 Text ca i tl i th E i, 29 Phone call | i | | tl i 8 Total Wi 40 8 6 7 3 4. 49 Sample of Check Sheet Scatter Diagrams are the best way to represent the value of two different variables. They present the relationship between the different variables and illustrate the results on a Cartesian plane. Then further analysis can be done on the values. 165 Hospital Nursing Service Administration Manual

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= T T T T T 0 5 10 15 20 Process input Control Charts are good tools for monitoring performance and can be used to monitor any process that relates to the function of an organization. These charts allow you to identify the stability and predictability of the process and identify common causes of variation. Rule 41: One point is more than 3 standard deviations from the mean Pareto Charts are charts that contain bars and a line graph. The values are shown in descending order by bars and the total is represented by the line. They can be used to identify a set of priorities so you can determine what parameters have the biggest impact on the specific area of concern. 166 Hospital Nursing Service Administration Manual

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Quality Management Pareto Chart is a graphic tool which presents sources of problems in order from most to the least significant. It is based on the principle of “the vital few and the trivial many”, or the “80-20 rule” which means that 80% of the problems result from the 20% of the causes. When to use a Pareto Chart To identify primary customers in the process. To select which problems should be studied first. To narrow down cause of the problems in order to identify the root cause. To identify where the costs of poor quality are impacting the process. How Pareto Chart enhance process improvement Analyze how small percentage (typically 20%) of the problems causes a large percentage (typically 80%) of the process variation, defects, complaints or cost. Provide a graphic demonstration of how much damage can be caused by only a few vital errors and how much progress would be achieved if “vital few” key errors were eliminated. How Pareto Chart is developed Define the categories to be used. Sort the data into the defined categories and arrange the categories in descending order. Make a bar graph based on the collected data, with the highest bar on the left: adding a cumulative frequency trend line. Check the chart for a Pareto pattern (where the highest categories are responsible for most of the effects). Use the Pareto Chart as a guide for action or further analysis. How Pareto Chart is constructed Decide what data is to be analyzed. Identify what types of problems are to be investigated (defects, errors, etc.). Use a tally sheet to record and total various items Prepare a Pareto Table. Determine the cumulative count of each category. Get the cumulative percentage. 167 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Pareto Chart of Late Arrivals by Reported Cause 168.0 151.2 134.4 117.6 100.8 f 84.0 67.2 50.4 Public transportation Treffic Child care ee ———— Oversiept a Emergency 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Cause-and-Effect Diagram (also known as Fishbone diagram) can be used to understand the root causes of business problems. Because businesses face problems daily, it is necessary to understand the root of the problem so you can solve it effectively. Fishbone Diagram/Ishikawa Diagram is a technique used to generate, organize and display the factors that might contribute to a problem. It is also called Cause-and- Effect diagram. It is a problem-solving tool which indicates causes and effects and how they interrelate. Uses of Cause-and-Effect diagram e For identifying the possible causes of a problem by sorting and displaying them; e For analyzing the current process by reviewing all potential factors that may cause a problem; e For identifying probable and root cause of a problem; For addressing a resistance to change, it helps the team identify alternative solutions. How it is constructed e Step 1. long arrow as the central spine pointing to the box. Write the problem statement in an enclosed box at the right. Draw a Problem Statement 168 Hospital Nursing Service Administration Manual

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Quality Management Step 2. Identify the major categories of causes and place them in the boxes which are connected by arrows to the central spine. Man Machine \ \ Problem Fa VA Statement Material Method CAUSE EFFECT Step 3. Brainstorm specific causes under each category. MAN MACHINE (People) (Equipment) Statement METHOD (Procedures) MATERIAL (Supplies) Step 4. For each specific cause listed, continue asking “what cause this?” until the root causes is identified. Problem Statement G1 G2 METHOD (Procedures) Hospital Nursing Service Administration Manual 169

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The Management in the Delivery of Nursing Care e Step 5. Check the logic of each chain by walking through the diagram in both directions. e Step 6. Decide which potential root causes are the most likely to contribute to the problem. Circle these causes. SYSTEM New Lab Tech —————— Request not legibly written No point person No orientation ee{eve Lab Tech in a hurry gab tech inahon Problem Statement /.. Code of Tube not clear Old Stock MATERIAL 170 Hospital Nursing Service Administration Manual

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Safety in Health Care 11 SAFETY IN HEALTH CARE Introduction Safety in healthcare organizations aims to prevent harm to patients their families and friends, healthcare professionals, contract of service workers, volunteers, and the many other individuals whose activities bring them into a safe environment. Safety is one aspect of quality that includes not only avoiding preventable harm, but also making appropriate care available-providing effective services to those who could benefit from them and not providing ineffective or harmful services. In response to the call of the World Health Assembly (WHA), the Department of Health has issued Administrative Order No. 2008-0023 which mandates the reinforcement and institutionalization of the implementation of quality assurance for patient safety where it is regarded as one of the dimensions of quality care (Institute of Medicine, 2000). In 2019, the Administrative Order on National Policy on Patient Safety in Health Facilities was updated. Definition of Terms e Patient Safety is defined as “the prevention of harm to patients through avoidance and amelioration of risk, adverse outcomes, or injuries stemming from the processes of healthcare. It is the degree to which the risk of an intervention and risk in the care environment are reduced for a patient and other persons, including healthcare providers. e Prevention of harm to patients it is freedom from accidental injury and ensuring the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. e Patient-Centered is providing care that is respectful of and responsive to patient preferences, needs, values and ensuring that patient values guide all clinical decisions. e No Blame Culture a non-punitive culture encouraging voluntary reporting of events. e Sentinel Event most serious adverse events which cause permanent harm, severe or temporary serious injury or death. e Timely means reducing waiting time and sometimes harmful delays for both those who receive and those who give care. 171 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Efficient means avoiding waste, including waste of equipment, supplies, ideas and energy. e Equitable means providing care that does not vary in quality because of personal characteristics such as gender, geographic location and socio economic status (Institute of Medicine (IOM) 2001). Key Elements of Patient Safety

1. Leadership. Leadership and political commitment are essential at the health facility level where patient safety becomes an integral component of quality care. The leadership shall address strategic priorities for institutional development, its culture and infrastructure, engage its various stakeholders communicate and build awareness.
2. Institutional Development. Refers to approaches to institutionalize patient safety and quality in the health facilities will have to consider financial and human resource; facility and equipment management; strengthen management responsibility, authority and competency; formulate standards of what is expected from health providers; communicates; provide training; enforce the standards that comes with the policies and give the patients a voice through a feedback system or a patient satisfaction survey.
3. Reporting System. The National Patient Safety Committee shall develop and institutionalize a pro-active reporting and learning system that requires its leadership to encourage reporting of events.

Feedback and Communication. Performance feedback and benchmarking mechanism to communicate leadership responses to the reports shall be established to demonstrate commitment to patient safety and ensure continuous improvement. 5. Adverse Event Prevention and Risk Management. Risk and reduction strategies thorough patient risk assessment, patient feedback survey, health technology assessment and safety assessment code. 6. Disclosure of Reported Serious Events. The reporting system ensures confidentiality of individual cases. The events can be made available to the public through disclosure of results of investigation, summary reports or annual reports that summarize events and actions taken. 7. Professional Development. Training and supervision of the healthcare staff to improve their decision and clinical judgments are imperative. It is necessary to instill standard norms of behavior of courtesy, promptness and efficiency among the healthcare workers and improve the quality of service given to patients. 8. Patient-Centered Care and Empowerment of Consumers. Patients must be at the center of patient safety initiatives and must be partners in all aspects of the process. Patient-centered care and patient safety is a national priority and a core agenda to improve quality care in all health facilities to protect patients from faulty systems. 172 Hospital Nursing Service Administration Manual

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Safety in Health Care Ten (10) Reasons for Global Patient Safety e Patient safety is a serious global public health issue. There is now growing recognition that patient safety and quality is a critical dimension of universal health coverage. Since the launch of the WHO Patient Safety Program in 2004, over 140 countries have worked to address the challenges of unsafe care. © One in 10 patients may be harmed while in the hospital. Estimates show that in developed countries as many as 1 in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of errors or adverse events. e Hospital infections affect 14 out of every 100 patients admitted. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire health care-associated infections (HAIs). Hundreds of millions of patients are affected worldwide each year. Simple and low-cost infection prevention and control measures, such as appropriate hand hygiene, can reduce the frequency of HAIs by more than 50%. e Most people lack access to appropriate medical devices. There are an estimated 1.5 million different medical devices and over 10,000 types of devices available worldwide. The majority of the world’s population is denied adequate access to safe and appropriate medical devices within their health systems. More than half of low- and lower middle-income countries do not have a national health technology policy which could ensure the effective use of resources through proper planning, assessment, acquisition, and management of medical devices. “While patient safety and healthcare quality have certainly received substantial attention for more than 10 years now, the actual investments in patient safety still pale beside investments in traditional biomedical research” e Unsafe injections decreased by 88% from 2000 to 2010. Key injection safety indicators measured in 2010 show that important progress has been made in the reuse rate of injection devices (5.5% in 2010), while modest gains were made through the reduction of the number of injections per person per year (2.88 in 2010). e Delivery of safe surgery requires a teamwork approach. An estimated 234 million surgical operations are performed globally every year. Surgical care is associated with a considerable risk of complications. Surgical care errors contribute to a significant burden of disease despite the fact that 50% of complications associated with surgical care are avoidable. e About 20%-40% of all health spending is wasted due to poor-quality care. Safety studies show that additional hospitalization, litigation costs, infections acquired in hospitals, disability, lost productivity, and medical expenses cost some countries as much as US$ 19 billion annually. The economic benefits of improving patient safety are therefore compelling. e Healthcare has a poor safety record compared to other industries. Industries with a perceived higher risk such as the aviation and nuclear industries have a much better safety record than health care. There is a 1 in 1,000,000 chance of a traveler being harmed while in an aircraft. In comparison, there is a 1 in 300 chance of a patient being harmed during health care. 173 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Patient and community engagement and empowerment are keys. People’s experience and perspectives are valuable resources for identifying needs, measuring progress, and evaluating outcomes. e Hospital partnerships can play a critical role. Hospital-to-hospital partnerships to improving patient safety and quality of care have been used for technical exchange between health workers for a number of decades. These partnerships provide a channel for bi-directional patient safety learning and the co-development of solutions in rapidly evolving global health systems.(World Health Organization (2014) Strategies that Promote Patient Safety A. Health facility operations and management systems that promote Culture of Safety 1. Leadership and Management commitment to patient safety e Patient safety as a strategic priority in health facility policies, organizational structure, plans and health program Promoting the use of checklists in patient care process Establishing a clinical audit system for system improvement Conducting regular patient safety executive walk-rounds to promote Culture of Safety e Ensuring that hospital managers, clinicians, and all levels of health- care staff are responsible for patient safety at their levels and held accountable 2. Ensuring a safe environment in the health facility e Compliance to environmental standards for health care e Displaying of warning signs marking unsafe areas and precautions on safety issues (fall, medication alert, radiation, etc.) Ensure there is appropriate and safe supply of food and drinks for patients and staff Conforming to guidelines on safe management of chemical and radiologic waste Establish a preventive maintenance program for its physical environment Implement an emergency plan Establishing systems to ensure standards of cleaning and sanitation 3. Health personnel safety established e Implementing occupational health program for all staff e Ensuring clinical staffing levels reflect patient needs at all times e Adherence to national labour laws e Screening before employment and regularly afterwards for transmissible infections e Protecting from health-care associated infections, including provision of vaccination 174 Hospital Nursing Service Administration Manual

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Safety in Health Care 4. Medical records system is completed e Using standardized codes for diseases, diagnosis, and procedures e Establishing and maintaining medical records archiving system e Ensuring that each patient has a single completed medical record with unique identifier e Developing the infrastructure and capacity to introduce and strengthen information technology to minimize errors in patient care 5. Patient-centered care e Obtaining informed consent for treatments and procedures carrying risk to patients e Communicating and counselling patients and their families and also the staff involved when an adverse event occur e Involving participation from patients and their respective families in decisions regarding their care e Encouraging and setting up mechanisms for reporting of incidents by patients and their families e Involving participation of patients and consumer advocates in patient safety committees and patient safety initiatives B. Assessment of the nature and scale of adverse events 1. Implementing a surveillance system for nature and scale of adverse events e Conducting a baseline assessment of the overall burden of unsafe care in the facility e Developing patient safety incident surveillance e Establishing a system of analyzing all reported incidents to guide appropriate intervention at the institutional and health facility levels to prevent their recurrence 2. Use of incident reporting system and risk mitigation strategies e Employ risk mitigation strategies to manage the effects of adverse events e Developing a system of reporting and disclosure for learning from all adverse events, sentinel events, and near misses e Conduct Patient Safety risk identification and management plan proactively (Root Cause Analysis and /or Failure Mode and Effects Analysis) C. Training and capacity building of health workforce sensitive to patient safety 1. Strengthening education, training and professional performance inclusive of skills, competence and ethics of healthcare personnel e Developing standard treatment guidelines and standard operating procedures for healthcare practice and ensuring compliance e Establishing accreditation of healthcare professional education and training for the improvement of standards 175 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Identifying knowledge, skills, attitude gaps of health professional and providing learning and development avenues to address 2. Improving the understanding and application of patient safety and risk management e Addressing patient safety at the time of employment and induction and making it a component of performance reviews e Conducting periodic assessments of healthcare staff on their understanding and awareness of patient safety principles and practice e Encouraging patient safety as part of bedside teaching, onsite learning and field work e Reinforcing a Culture of Safety by advocacy, awareness, patient safety campaigns, and behavior modification methods for involvement by all healthcare personnel D. Preventing and controlling Healthcare-Associated Infection (HAI) 1. Strengthening the Infection Prevention and Control (IPC) Program across all healthcare services e Establishing evidence-based IPC policies, technical guidelines, standard operating procedures that are aligned with the national IPC policy e Creating the IPC committee or team that will oversee the Infection Prevention and Control program of the health facility in all services e Building awareness on the principles of hygiene and sanitation for patients including visual reminders e Strengthening microbiology laboratory support e Implementing policies and procedures for rational use of antibiotics e Building the awareness and capacity of health-care workers, sanitary and supervisory staff in cleaning and sanitation and occupational safety 2. Employing a system to reduce HAI in the facility e Improving hand hygiene practices using multimodal strategy for hand hygiene e Undertaking surveillance, identification and prevention of significant HAI e Utilizing effective barrier precautions and isolation procedures e Providing appropriately cleaned, disinfected or sterilized equipment for patient care e Providing appropriate design and ventilation of health facility for infection control, sinks and running water, supplies for hand hygiene and other IPC practices, isolation facility and sterile supplies E. Implementing of Patient Safety key priority areas 1. Patient Identification Procedures and Protocols e Standardizing patient identification procedures to have at least two identifiers, including full name and date of birth (room number is not 176 Hospital Nursing Service Administration Manual

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Safety in Health Care one of them), for all patient care processes (procedures, transfer, or administration of medication and blood or blood components) e Providing clear protocols for maintaining patient sample identities throughout pre-analytical, analytical, and post-analytical processes e Using of biometric technologies or bar coding with check digits for patient identification e Providing clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name e Developing non-verbal approaches for identifying comatose or confused patients e Developing and implementing a process to improve the accuracy of patient identification and confirmation prior to procedures 2. Effective Communication e Creating policies against use of abbreviations in medical orders and in patient charts e Developing and implementing a process to improve the effectiveness of verbal and/or telephone communication among caregivers (i.e, reading back) e Implementing a process and protocol for reporting critical results of diagnostic test e Use of standardized methods, forms, or tools to facilitate consistent and complete handovers and referral of patient care (SBAR. IPASS the BATON) a. SBAR-standardized technique to facilitate communication during transitions of care S Situation: What is the situation? e identifying self, the unit, and the patient (by using two patient identifiers-name and birth date) e briefly state the problem: what it is, when it started, and the severity B_ Background: Provide background information relevant to the situation (i.e. admitting diagnosis, list of medications, allergies, most recent vital signs, other clinical information) A Assessment: What is your assessment of the situation? R_ Recommendation: What is your recommendation of the situation (i.e.. patient to be admitted, to be seen now, or an order to be changed) 177 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care b. I PASS THE BATON - an effective tool of a hand-off checklist of critical information I Introduction of self and your role P Patient-name, identifiers, age, gender, location A Assessment-presenting chief complaint, vital signs, symptoms diagnosis S_ Situation-current status/circumstance, level of uncertainty, recent changes, code status S Safety Concerns-critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.) [THE] B_ Background-comorbidities, previous episodes, current medications, family history A. Actions-what actions were taken or are required? T Timing-level of urgency and explicit timing and prioritization of actions O Ownership-who is responsible — (nurse/doctor/team)? —_ Include patient/family responsibilities N_ Next-what will happen next? Anticipated changes? What is the plan? Types of Errors 1. 2. Adverse Health Care Event is n event or omission arising during clinical care and causing physical or psychological injury to a patient. Error is failure to complete a plan action as intended, or the use of an incorrect plan of action to achieve a given plan. Health Care Near Miss refers to a situation in which an event or omission (or sequence) arising during clinical care fails to develop further whether or not as the result of compensating action, thus preventing injury. Adverse Drug Reaction is any response to a drug which is noxious, unintended and occurs at doses used for prophylaxis, diagnosis or therapy (Predictable/Unpredictable). Medication Error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer. Sentinel Error refers to a surgery on the wrong body part, surgery on the wrong patient, patients receiving the wrong medication. 178 Hospital Nursing Service Administration Manual

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Safety in Health Care Medication Errors A medication error is broadly defined as dose of medication that deviates from the physician’s order as written in the patient’s chart or from standard hospital policy and procedures, except for errors of omission. The medication dose must actually reach the patient; that is, a wrong dose that is detected and corrected before administration to the patient is not a medication error. Prescribing errors (e.g., therapeutic inappropriate drugs or dose) are excluded from this definition. In the medication area, vigilance, accuracy, careful attention, and meticulous knowledge of medications and their administration are also needed. In addition, nurses should conduct clinical research that examines modes of delivering medications to patient in order to answer the following: e Do error rates differ when one nurse per unit is responsible for administering medications, as opposed to several nurses administering medication to their assigned patients in one unit? e Are there safer ways of giving medications? e Another strategy for minimizing risk of injury by medication error is to evaluate labeling, packaging, coding and other aspects of medicine identification. Encourage all members of the nursing staff to notify the Supervising Nurse, the hospital therapeutic committee, and the manufacturer, in-writing, of any problems, questions, or concern about the administration of medications. e Ifa medication error is detected, the patient’s physician must be informed immediately. e An incident report should be prepared describing any medication error observed in the administration of a medication. This report should be prepared and sent to the Nursing Service Office within 24 hours. This report should be analyzed and any necessary action taken, to minimize the possibility of their recurrence. Properly utilized, this incident report will help ensure optimum drug use control. Medication Error Policy Appraisal. The merits of a medication error policy or any policy can only be measured in terms of results. e Are medication errors being reported promptly? Did the nurse act properly and procedurally? Is there a marked decrease in repeat offenders? Are the educational and corrective measures reviewed constructively? Have grievances as a result of corrective measures decreased? What seems to be the overall feeling of the staff towards the medication error policy? 179 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Nine Categories of Medication Error e Omission error: the failure to administer an ordered dose. However, if the patient refuses to take the medication, no error has occurred. Likewise, if the dose is not administered because of recognized contraindications, no error has occurred. © Unauthorized-drug error: administration to the patient of a medication dose not authorized for the patient. This category includes a dose given to the wrong patient, duplicate doses, administration of an unordered drug, and a dose given outside a stated set of clinical parameters (e.g., medication order to be administered only if the patient’s blood pressure falls below a predetermined level). e Wrong dose error: any dose that is wrong number of ordered units (e.g., tablets) or any dose above or below the ordered dose by a predetermined amount (e.g., 20 percent). In the case of ointments, topical solution, and sprays an error occurs only if the medication order expresses the dosage quantitatively (e.g., 1 inch of ointment or two 1 second sprays). e Wrong-route error: administration of a drug by a route other than that ordered by the physician. Also included are doses given via correct route but a wrong site (e.g., left eye instead of right). e Wrong-rate error: administration of a drug at the wrong rate, the correct rate being that given in the physician’s order as established by hospital policy. e Wrong-dosage form error: administration of a drug by the correct route but in different dosage form than that specified or implied by the physician. Examples of this error type include use of an ophthalmic ointment when a solution was ordered. Purposeful alteration (¢.g., crushing of a tablet) or substitution (e.g., substituting liquid for a tablet) of an oral dosage form to facilitate administration is generally not an error. e Wrong-time error: administration of dose of a drug greater than + X hours from its scheduled administration time, X being as set by hospital policy. e Wrong preparation of a dose: incorrect preparation of the medication dose. Examples are: incorrect dilution or reconstitution; not shaking a suspension; using an expired drug; not keeping a light-sensitive drug protected from light; and mixing drugs that are physically/chemically incompatible. e Incorrect administration technique: situation when the drug is given via the correct route, site, and so forth, but improper technique is used. Examples are: not using the Z-track injection technique when indicated for a drug; incorrect instillation of an ophthalmic ointment; and incorrect use of an administration device. Oftentimes, medication error occurs due to the system of applying standards of care. A review of the system with the personnel involved would pinpoint the cause of error that, otherwise, could have been prevented. 180 Hospital Nursing Service Administration Manual

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Safety in Health Care The Nurse’s Responsibility for the Patient’s Safety Nurses are responsible for providing safe care both physically and psychologically. Equipment, such as stretchers, wheelchairs and beds should likewise promote an environment conducive to recovery. Restraints like confining a person in bed can be misinterpreted as a form of punishment, therefore, it cannot be instituted without a doctor’s order. However, in case where a patient is in danger of hurting himself and others, the nurse can apply the necessary restraint provided that an accurate documentation is made. Emergency Care e When a patient is brought to the Emergency Room (ER) for treatment, it is implied that he/she is consenting to the measures the physician deems necessary for his/her condition. e Nurses should observe and properly record the patient’s condition and the treatment he/she received. In many cases, patients brought to the ER are medico-legal cases and the nurses must be conscious of its legal implications to them and the hospital. e A written consent should be obtained from the patient or in cases of children, from their parents. It is to be noted, however, that in emergency cases, treatment may be instituted as a means to save life. The doctor attests to this and the patient signs it. This is called therapeutic privilege on the part of the doctor. Consent (Right to Informed Consent) e Patients have the right to choose whether they desire medical care or not. A consent signed by the patient should be obtained before beginning any treatment or care. The patient must be aware of the treatment that would be given to him/her, the possible complications, danger and risks that may take place and other alternatives to the proposed therapy or treatment which may be considered. The patient has the right to consent or refuse such treatment. e The general consent taken upon admission is for initial treatment. Special procedures, such as: surgery, biopsy, spinal puncture, blood transfusion and x- ray procedures necessitating the administration of dyes, would require another consent. A patient who consent must have the legal capacity to do so, meaning he is of legal age, and knows what he is consenting to. Patients who are sedated, distraught, or who cannot comprehend cannot give an informed consent. e No consent is necessary for emergency cases where a patient’s life is at stake. However, this should be properly witnessed and the doctor should make the necessary notation on the chart. e When a patient refuses to give his/her consent, verify his/her reason, he may just need further explanation. However, should the patient still refuse, he 181 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care cannot be forced to sign the consent. This reaction should be properly noted on the patient’s chart through a waiver. Therapeutic Orders e Therapeutic orders should be legal, written, clear, timed and signed by the ordering physician. Signing an order is the legal proof that such an order has been made. If the order is unclear, verify from the ordering physician. Do not risk the patient’s life with an incorrect or an unclear order. e Medicine administration is a high risk area because errors may be fatal. Nurses should be familiar and kept updated with drug preparation, dosage, action, route, frequency, side effects and adverse reactions. e Since the quality of care given to patients is reflected in their charts, it is imperative that the nurses’ notes be clear, accurate and up-to date. What is not charted has not been observed, nor administered nor done. e There are occasions when nurses give telephone reports to physicians about changes in the patients’ conditions. Information given through telephone should be accurately transcribed by the receiving nurse in written form especially if this pertains to medications, or if significant events or changes in client’s condition have occurred. There are legal risks in telephone orders. These may be understood or misinterpreted by the receiving nurse. They may sound unclear because of some trouble in the telephone line. Most importantly, if the signature of the ordering physician was not present and this order may be denied in case errors exist or when court litigations arise. e Only in an extreme emergency and when no other physician is available should a nurse receive telephone orders. The nurse should read back such order to the physicians to make sure the order has been correctly received. The nurse should note the date and time when the order was made, the name of the physician making the order, then sign his/her own name including designation. The ordering physician should sign the order as soon as he arrives in the unit. Clear hospital policies with regards to receiving telephone orders should be established to avoid misunderstanding and legal risks. The Generics Act Law (RA 6675) An Act to promote, require and ensure the production of an adequate supply, distribution, use and acceptance of drugs and medicines identified by their generic names. A prescription and orders for drugs and medicines in DOH facilities shall be specified in generic terminology. In all written orders, the generic name of the drugs, active ingredients shall be stated. All orders shall use generic names exclusively. The role of the nurse in relation to generics is not only as a drug administrator but also as an educator, a motivator, a coordinator and an evaluator of the efficacy of such drugs. 182 Hospital Nursing Service Administration Manual

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Safety in Health Care Medication Rights Observation of the Medication Rights will prevent Medication errors legally ordered by a physician. e Right Order is always written, dated and signed by the ordering physician. e Right Medicine. Medicines may have similar names. Be careful in examining the label. e Right Dose. When in doubt, double check with the physician. It is better to be safe than to be sorry. e Right Patient. There are times that patients have the same name and surname. Verify the middle initial. Ask the patient to state his/her name. e Right Route and Frequency. Some procedures are given orally or parenterally. Check several times to prevent errors. e Right Assessment. Assess whether patient has any allergies, have been previously administered, or any information that is significantly relative to administration of drugs. e Right Approach. Patients who are having problems with drug administration especially children, will be more cooperative if approached in gentle, persuasive manner that builds trust and confidence in the patient. e Right Feedback to the ordering physician, is important so he will know the patient’s progress. e Right Observation. Patient should be regularly visited, to detect if there are any symptoms of reactions. e Right Documentation. This is a legal requirement. What is not documented has not been observed nor given. Indicators and Parameters of Safety The Patient Safety Indicators (PSIs) are a set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are likely amenable to prevention by changes at the system or provider level. (PSIs) are a set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses. The PSIs can be used to help hospitals identify potential adverse events that might need further study; provide the opportunity to assess the incidence of adverse events and in hospital complications using administrative data found in the typical discharge record; include indicators for complications occurring in hospital that may represent patient safety events; and, indicators also have area level analogs designed to detect patient safety events on a regional level. 183 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care i & SIN a2 8. Medication error Falling incident Needle stick injury Splash/spills incident Hospital acquired infection like CLABSI, CAUTI, VAP, HAPU / healthcare associated infection Blood and blood component transfusion error Intravenous Therapy complications like infiltration, extravasation and phlebitis Hazardous materials exposure Benefits of Checklists in Health Care Checklists used in the medical setting can promote process improvement and increase patient safety. Implementing a formalized process reduces errors caused by lack of information and inconsistent procedures. Checklists have improved processes for hospital discharges and patient transfers as well as for patient care in intensive care and trauma units. Along with improving patient safety, checklists create a greater sense of confidence that the process is completed accurately and thoroughly. Checklists can have a significant positive impact on health outcomes, including reducing mortality, complications, injuries and other patient harm. Clinical quality. This guide includes checklists, developed by Cynosure Health, for these! 0 areas: 1. Adverse drug events (ADEs) Catheter-associated urinary tract infections (CAUTIs) Central line-associated blood stream infections (CLABSIs) Early elective deliveries (EEDs) Injuries from falls and immobility Hospital-acquired pressure ulcers (HAPUs) Preventable readmissions Surgical site infections (SSIs) . Ventilator-associated pneumonias (VAPs) and ventilator associated events (VAEs) 10. Venous thrombo embolisms (VTEs) to prevent process breakdowns due to human factors, each checklist identifies the top evidence-based interventions that health care organizations can implement and test to reduce harm CRN AAAYWL Nursing Actions to Improve Patient Safety

1. Knowledge and implementation about healthcare policies and procedures.
2. Open communication and teamwork among all other healthcare providers.
3. Review the medication rights before giving the medications.
4. Engage in creating and updating reporting systems to avoid a blaming culture.
5. Involve in research and evidence-based activities for better decision making. 184 Hospital Nursing Service Administration Manual

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Safety in Health Care 6. Be updated on all lifesaving certification like CPR, BLS, ACLS, PALS, NALS and other Nursing Specialty Certification Programs. 7. Engage in hospital committees to make the healthcare system safe effective and patient-centered. 8. Be responsible in reporting all errors and near misses not only for the patient to prevent sentinel and adverse events to happen again. . Ensure better lighting and less clutter in the work areas. 10. Ensure the staffs are trained to operate the medical equipment like ventilator, infusion pump, and warmer. Nurses were asked to engage in the following activities: e Promote awareness about changes in the healthcare system that undermine quality and safety of patient care. e Support the development of a National Center for Patient Safety and the establishment of a nationwide mandatory state-based error reporting system. e Support the development and implementation of performance standards by regulators and accrediting agencies that require health care institutions and systems to implement patient safety programs and processes with defined executive responsibility. e Support the implementation of proven medication safety systems and practices by healthcare organization. e Promote passage of whistle-blower legislation that protects the essential role of nurses in efforts to correct system errors. « Demonstrate the improvement of quality of care and reduction of errors through collection of data using nursing quality indicators. e Promote nursing research on patient safety and educate nurses in the science of system safety issues. Tips on How to Improve the System and Prevent Future Errors from Occurring 1. Adapt a culture of safety in the workplace 2. Focus on the task at hand 3. Reduce distracting noise to prevent accidents/errors 4. Develop a personal note-taking system Implementing Policies on Accidents Standard Operating Procedure Person/s Responsible When a patient had an accident e.g., fall: e Bring the patient back to bed if his condition permits. Assigned nurse or whoever saw e Notify the Supervising Nurse on duty and ROD. Inform the patient them of the accident. Nurse on duty e Do physical assessment. Check for any injury and extent of injury. Assigned nurse and ROD e Get neurological vital signs. e Render emergency care and carry out doctors’ orders such as cold compress application, IV fluids insertion, O2 inhalation etc. Assigned nurse Assigned nurse and ROD 185 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Standard Operating Procedure Person/s Responsible e Accomplish an accident report in duplicate copy with the Assigned nurse medical examination report of the doctor who examined the patient. e Submit two copies of the report to the Nursing Office Senior nurse/Charge nurse thru channel, within 24 hours after the accident. When the visitor or watcher had an accident: Render emergency care on the spot. Nurse on duty and ROD Inform Supervising Nurse on duty Senior nurse/Charge nurse Send the visitor or watcher to ER for treatment if Senior nurse/Charge nurse condition permits. e Report to Security Guard for medico-legal purposes. ER nurse When nursing personnel had an accident during his/her tour of duty: e Render emergency care on the spot Nurse on duty and ROD e Notify ROD / Medical Specialist Senior nurse/Charge nurse e Notify Supervising Nurse on duty Senior nurse/Charge nurse e Send the personnel to ER for treatment if condition Senior nurse/Charge nurse permits Accomplish an incident report in duplicate copy Senior nurse/Charge nurse Accomplish a medical examination report/medical certificate Submit 2 copies of the accident report with the attached medical examination report to the Nursing Office thru channel within 24 hours after the accident Give two copies of the accident report and the medical examination report to the personnel concerned for future reference (Employment Compensation or Disability Claims) ER ROD Senior nurse/Charge nurse Senior nurse/Charge nurse Patients’ Safety Implementing Policies Bedside rails and/or restraints should be used routinely for children, restless patients, the aged, those under sedation and unconscious patients. Suicidal patients should always be provided with a 24 hour watcher. Alert other caregivers of patients’ suicidal tendencies. Strictly “No Smoking” within hospital premises is enforced. Make sure floors are free of debris that might cause patients to slip and fall. Spilled liquids should be wiped immediately. Encourage janitors to use dry mops for slippery/wet areas. Patient’s unit and hallway should be neat and free from hazardous equipment, footstools, electrical cord, slippers, shoes, IV stand, etc. Place articles such as call light, cups etc. within the patient’s reach. Nurses should take turns in making rounds, checking patient’s condition at least every hour and more frequently to high-risk patients. Stretchers, wheelchairs and beds’ wheels should be locked when not in use. Security guard on duty should be notified of any suspicious strangers loitering in the patient’s unit/ward. 186 Hospital Nursing Service Administration Manual

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Safety in Health Care e Unsafe and defective equipment and devices should be reported or turned over to the Maintenance/Engineering Department for repair or condemnation. e Fire extinguishers available in the unit should be changed annually with the Maintenance Personnel. Fire exits are checked for safety purposes. On admission, patient’s condition is assessed. Proper documentation should be made on the patients’ chart. Example: The patient taking drugs that would affect movement or ambulation. He/she may need help in getting out of bed or walking. Nursing Actions That Improve Patient Safety e Nurses need to be knowledgeable about their healthcare facility policies and procedures and always follow them. e Nurses should have open communication with one another as well as other healthcare professionals. They should not be afraid to question orders or medications that seem out of the ordinary. e Nurses must ALWAYS review the medications rights before giving medications. e Nurses need to be involved in creating and updating reporting systems that avoid blaming individuals but rather encourage learning from the error, so that it can be prevented in the future. e Nurses should stay current with research that affects their area of practice. so that they can be involved in evidenced- based decision making when taking care of patients. e Nurses should stay current on all lifesaving certifications, such as BLS, ACLS, PALS and IV therapy to avoid missing information that could affect patient safety. e Nurses ought to be part of hospital committees that focus on making the healthcare system safe, effective, patient-centered and timely. e Nurses must report all unsafe care, errors and “near miss” not only for the patient it affects but to prevent it from happening again. e Patients are given identification bracelets showing their names and allergies. e Better lighting and less clutter in work areas where medications are prepared, keeping distractions to a minimum and keeping noise levels down. e Drug companies and health care facilities are also standardizing medication labels and packaging. e Medications that can have a particularly dangerous effect are being mark as “high alert”. e Many hospitals are investing in technology to minimize errors such as machines that dispense medication for just one patient at a time. 187 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Occupational and Environmental Health Nursing Is the specialty practice that provides for and delivers health and safety programs and services to workers, worker populations and community groups. The practice focuses on promotion and restoration of health prevention of illness and injury and protection from work related and environmental hazards. Role of Occupational Health Nurses e Case Management refers to providing treatment, follow up and referrals and emergency care for job related injuries and illnesses. Occupational health nurses act as gatekeepers for health services, rehabilitation, return to work and case management issues, and are keys to employers’ health care quality and cost containment strategies. © Counseling and Crisis Intervention involves counseling workers about work- related illness and injuries, substance abuse and emotional and/or family problems. They handle referrals to employee assistance programs and/or other community resources and coordinate follow up care. e Health Promotion is the teaching of skills and developing health education programs that encourage workers to take responsibility for their own health. Smoking cessation, exercise, nutrition and weight control, stress management, control of chronic services are just a few of the preventive strategies to keep workers healthy and productive. e Worker and Work Place Hazard Detection Includes monitoring the health status of workers by conducting research on the effects of workplace exposures, gathering health and hazards data, and using the data to prevent injury and illness. Personnel Safety Implementing Policies e Always observe necessary safety measures when using wheelchairs, stretchers, beds and other equipment available for the patient. Never operate electrical equipment with wet hands. Do not attempt to use an equipment unless, you are familiar with its operation. Be sure that the electrical equipment is plugged into the proper type of outlet. Never smoke or allow anyone to smoke in a room where oxygen is in use. This is a “No Smoking” hospital. e Report any unsafe conditions such as following to the janitorial supervisor or Supervising Nurse :

• Wet and slippery floors
• Defective equipment
• Inadequate lighting e Fire drills are conducted so that employees know how to act during emergencies. e Needlestick injuries surveillance. Recommend staff for immunization on the following: Flu Vaccination, Pneumonia, Rabies, Hepatitis B and C. 188 Hospital Nursing Service Administration Manual

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Safety in Health Care Infection Prevention and Control (IPC) The goal of an organization’s infection and control program is to identify and reduce the risk of acquiring and transmitting infections among patients, staff, health care professionals, contract workers, volunteers, students and visitors. The infection risks and program activities may differ from organization to organization depending on their clinical activities and services, patient’s population served, geographic location, patient volume and number of employees. Effective infection prevention and control program commonly have identified leaders, well-trained staff, methods to identify and proactively address infection risks, appropriate policies and procedures, staff education and coordination throughout the organization. It has become clear that countries should be prepared in meeting the challenge of emerging and re-emerging diseases. Critical to country preparedness is an existing National Standard on Infection Control that will be followed and implemented by all health facilities to ensure that transmissible infection are prevented and/or contained. The Department of Health, through the Health Facility Development Bureau, in collaboration with active partners from both the public and private sectors, developed the National Standards in Infection Prevention and Control for Healthcare Facilities. These standards will form the basis for future policies and programs that shall help healthcare facilities establish a strong, effective and relevant hospital infection control network in the country (Department of Health-Health Facility Development Bureau(DOH-HFDB) and the Philippine Hospital Infection Control Society, Inc. (PHICS) National Standards in Infection Prevention and Control for Healthcare Facilities, 2009). Importance of Infection Prevention and Control 1. Maintain a safe environment for patients and staff by reducing the risk of acquiring the healthcare-associated infections. 2. Prevent spread of transmissible diseases in healthcare settings through evidence based-control measures. 3. Learn the multidisciplinary approach in infection prevention and control practices particularly for the emerging and non-emerging infections. 4. Develop strategies to reduce hospital and community acquired infections through evidence-based research. 5. Respond effectively and efficiently to outbreak of infections within the healthcare facility community. 6. Provide support for infection control preparedness and response to public health emergencies of potential international concern. 7. Reduce patients’ length of stay and cost of confinement through stringent implementations of prevention and infection control policies and protocols. 189 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 8. Prevent complaints and litigations related to healthcare associated infections that can potentially incurred by patients, significant others, and staff. Purpose To coordinate, evaluate, and support the activities of the Infection Prevention and Control Program and to communicate with all departments of the healthcare facility to ensure the engagement and full support to the program by all stakeholders. The IPC advocates for the program shall ensure all resources needed are available. General Duties and Responsibilities (Infection Prevention and Control Nurse) Acts as coordinator to all hospital staff relevant to infection control. Identifies healthcare-associated (nosocomial) infections. Investigates type of infection and infecting organism. Participates in outbreak investigation. Conducts of surveillance of hospital infection. Participates in training of personnel. Assists in the development of infection control policies, reviews and approves patient care policies relevant to infection control. e Ensures compliance with local and national regulations. e Serves as liaison with other departments of the hospital. e Provides expert consultative advice to staff health and other appropriate hospital program in matters relating to transmission of infections. e Attends professional meetings and conferences on matters related to infection control. e Regularly monitors infection control practices and compliance of health care worker. e Monitors staff health in collaboration with the Employee Health Services Department to prevent hospital related infection among hospital staff. e Serves as preceptor in nursing training program. Conducts research studies relevant to infection control. @oee#ee#eeee@ The committee consists of multidisciplinary team members. Membership includes representation from the different services. Special meetings will be called by the Chair when circumstances dictate. (Refer to National Standards in Infection Control for Healthcare Facilities, 2009) All matters to be addressed by the committee should be brought to the attention of the chairperson, and/or the appropriate committee members. Documentation, discussions, conclusions, recommendations, assignments, actions, and approvals are documented in the minutes of the Committee meetings. Minutes are distributed to each Committee member and are forwarded to other appropriate staff 190 Hospital Nursing Service Administration Manual

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Safety in Health Care The program is executed by the Infection Prevention & Control (IPC) Department supported by the Infection Prevention Control Committee (IPC) through the following services: Surveillance of healthcare-associated infections (HAIs) Education Consultation Outbreak and exposure investigation Environmental health Occupational health and safety (Employee Health) Infection control is Everyone’s Responsibility, but the scope and magnitude encompassed by Infection Control requires a “key person” to coordinate the activities of the program. The Infection Prevention Chair is that “key person.” In some hospitals, Environmental Health is a complementary service to the IP&C Department depending on its size. The Environmental Health personnel assigned to the IP&C Department would be the appropriate person to report any environmental-health related infection concerns. Any staff, patient, and/or visitors of the healthcare facility may request infection control review and consultation as they relate to infection prevention and control activities, such as: ° Surveillance * Investigation * Research ¢ Statistics

• Education Standard Precaution — Infection Prevention and Control (Refer to National Standards in Infection Control for Healthcare Facilities, 2009) Standard precautions are meant to reduce the risk of transmission of blood borne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions, which are to be used as a minimum in the care of all patients. The nurses play a critical role in preventing and controlling hospital infections. Thus, nurses’ actions for infection prevention and control are the implementation of universal standard precautions. Nurse’s Role Nurses as the largest group of healthcare service providers in the nation, are vital members of this team. The IOM (Institute of Medicine) report on keeping patients safe: Transforming the Work Environment of Nurses made it explicit that nurses are the healthcare service professionals most likely to intercept errors and prevent harm to patients. Given the role that nurses play in care and quality improvement, it is important for nurses to know what proven techniques and interventions they can use to enhance patient and organizational outcomes. 191 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care The Department of Health, through the Health Facility Development Bureau, in collaboration with active partners from both the public and private sectors, developed the National Standards in Infection Control for Healthcare Facilities-DOH. These standards will serve the basis for healthcare organizations to establish a strong, effective and relevant hospital prevention and infection control program. The other references that can be utilized are materials from refutable related organizations like the Philippine Hospital Infection Control Society, Inc. (PHICS) and Disease Prevention and Control Bureau (DPCB). The primary role of a nurse is to advocate and care for individuals of all ethnic origins and religious backgrounds and support them through health and illness. However, there are various other responsibilities of a nurse that form a part of the role of a nurse, including to: Record medical history and symptoms Collaborate with the team to plan for patient care Advocate for health and wellbeing of patient Monitor patient health and record signs Administer medications and treatments Operate medical equipment Perform diagnostic tests Educate patients about management of illnesses Provide support and advice to patients oeeeeee#eee@ Multi-Drug Resistant Organisms (MDRQOs) are bacteria that are resistant to many or all available antibiotics. Methicillin-Resistant Staphylococcus Aureus (MRSA) and 2 Vancomycin-Resistant Enterococci (VRE) are important resistant microorganisms encountered in the hospital; Methicillin-Resistant Staphylococcus Aureus Management Vancomycin- Resistant Enterococcus Management. Extended Spectrum Beta-lactamases (ESBLs) and Carbapenem-Resistant Enterobacteraceae (CRE) are among primary resistant microorganisms of significant concern in the healthcare setting and are endemic in many hospitals of the GCC countries. Proper attention to these pathogens is critical to curtail further emergence of these highly resistant organisms. Standard Precautions Must Be Observed For All Patient Care Procedures A. Notification of the MDRO

1. The microbiology lab will notify the ward and Infection Prevention and Control (IPC) Department of the MDROs.

Patients previously discharged MDRO positive are flagged and documented by IPs. 3. Only IPs can de-flagged / remove MDRO alerts. 192 Hospital Nursing Service Administration Manual

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Safety in Health Care B. Management of MDRO-Positive Patients 1, Initiate contact precautions in addition to standard precautions. 1. Patient must be in a single room or can be cohorted with another patient with the same organism. 2. MDRO-positive patients who are in multi-bed rooms can be managed temporarily while waiting to be transferred to a single room or an appropriate cohort. a. Place a sign on the cubicle or curtain of the patient’s bed. b. Ensure easy access to PPE and alcohol-based hand rub. c. Practice strict standard precautions between interactions with patients in the room. d. Transfer to a single room or cohort with another patient with the same organism as soon as possible. Place a contact isolation sign on the outside of the isolation room door. Practice strict hand hygiene. 5. Cohort non-critical items such as stethoscopes and pressure cuffs with the patient. 7. Store minimum amount of supplies in the patient’s room. Use an isolation cart for extra supplies (kept outside the room). 9. Ensure that all staff understand and comply with the isolation precautions and hand hygiene protocol. 10. Limit the patient’s activity outside the room to treatments or tests. 11. Notify receiving departments/wards (e.g., Radiology, Endoscopy, Clinics, OR) of the patient’s isolation status when the patient must be transported for treatment/tests. 12. Ensure concurrent and terminal cleaning of the isolation room and equipment as per housekeeping procedure. 13. Handle/discard contaminated items as per Standard Precautions. me ad C. Medical 1. Request Infectious Diseases consultation as needed. 2. Discharge the patient from the hospital once his/her medical condition allows. 3. If the patient is being transferred to another hospital or healthcare facility while still colonized or infected with an MDRO, the transferring hospital is obliged to inform the receiving hospital of the details of the MDRO in order to ensure proper isolation. Emergency Medical Services (EMS) and other healthcare providers involved in transferring such a patient need to be made aware of the status of the patient and advise on proper Personal Protective Equipment (PPE), as well as, disinfection of the ambulance, as deemed necessary. D. Clearance/Discontinuation of Isolation 1. Discontinue isolation of MDRO-positive patient after consultation. 193 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care E. Screening of Healthcare Workers (HCWs) and the Environment.

1. Do not screen HCWs or the environment because it is not typically indicated and incurs unnecessary costs.
2. IPC may initiate such measures when indicated. F. Outbreak Management

Management of outbreaks will be coordinated by the IPC and will require the cooperation of medical, nursing, laboratory and other departments. G. Cleaning of the Patient’s Room

1. Perform regular or terminal cleaning. H. Linen
2. Keep a linen hamper in the isolation area. This policy describes the steps needed to prevent the spread of Methicillin-Resistant Staphylococcus Aureus (MRSA) to patients, staff, and visitors. Management of Patients with Suspected MRSA Infection or Colonization
3. Initiate empiric contact isolation precautions during the screening procedure, if possible. a. Screen all patients who are: i. Admitted to the intensive care units (ICU). ii. Transferred from other hospitals or have been treated in. Needlestick Injury In response to the risk of exposure, institutions have focused on primary prevention as a means of reducing the incidence of needlesticks and thereby decreasing the number of blood borne pathogen transmissions. Needlestick injuries still occur, however, and it is important that individuals in the health care field become well informed about the exposure risks and educated regarding the appropriate response. Needlestick injuries are wounds caused by needles that accidentally puncture the skin. Needle stick injuries are a hazard for people who work with hypodermic syringes and other needle equipment. These injuries can occur at any time when people use, disassemble, or dispose of needles. What are the primary pathogens transmitted? I. Human Immunodeficiency Virus (HIV). The average risk of sero conversion after a needle stick injury from a confirmed HIV source is approximately 0.3 percent without post-exposure therapy. Certain factors contribute to elevated risk: Increased depth of the puncture wound e Visible blood on the needle e Needle used in the vein or artery of the patient e Patient with terminal HIV as source of the fluid 194 Hospital Nursing Service Administration Manual

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Safety in Health Care 2. Hepatitis B Virus (HBV). The risk of acquiring hepatitis secondary to HBV percutaneous exposure varies based on the serological status of the patient. In the worst case scenario, if the patient has active replication of the virus (indicated by HBeAg-positive blood then the risk of developing clinical hepatitis is as high as 31 percent. When the patient has HBsAg-positive blood but is HBeAg-negative (indicating a less infective state), the risk is significantly lower, about | to 6 percent. 3. Hepatitis C Virus (HCV). The risk of HCV seroconversion after a needle stick injury from a patient infected with HCV is approximately 1.8 percent. Unfortunately, there is little evidence to support post exposure treatment as a means to decrease the risk of infection. What protocol should be followed after any needlestick? e First, do not panic. Protocols are in place to minimize the risk of infection after exposure. e Second, do not ignore the exposure. Acting within outlined timeframes can lead to a significant decrease in the transmission rate of certain infections. The following measures also should be taken: co The site should be immediately washed with soap and water. o The incident should be reported and an exposure report sheet completed. o The exposure should be assessed (type of fluid, type of needle, amount of blood on the needle, etc.) The exposure sources should be evaluated: a. HIV, HBV, and HCV status of the patient; b. Consent and testing of the patient for these diseases if the status is unknown; c. Likelihood of infection based on the community served by the hospital if the patient is not available to be tested. e Appropriate management of any positive exposure is necessary Policies on Needle Stick Injury e All health care workers who handle sharps should be properly oriented in its safe use and disposal. e All health care workers should handle needles, blades/lancets and sharp instruments carefully so that accidents can be prevented. e All used needles, blades/lancets and other sharp instruments should be disposed to punctured proof resistant container immediately after use. e Punctured proof resistant container should be accessible so that the operator can dispose immediately the sharp and avoid mixing it with other wastes. e All health care workers should practice safety techniques in handling sharps from use until disposal. 195 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care o DONOT RECAP NEEDLES. If recapping is necessary, USE SINGLE HAND TECHNIQUE or USE MECHANICAL DEVICE (forceps). o Always seek orientation on how to properly manipulate new gadget using sharp (e.g. CBG lancets). o Do not bend needle. Do not manipulate the capped needle. If needle should be removed from the syringe, always use forceps. © Use forceps in picking sharps debris or any equivalent. o Sharps should be pointing away from the operator when manipulated but not facing anybody and be aware of the persons beside you. o Do not overfill sharp containers and seal properly if ready for disposal. e Puncture proof resistant container should be available in the following areas at all time: o Medication room/TV trays o Laboratory o Procedure/treatment room o Anywhere sharps are used e All needles/sharp injuries should be reported for evaluation and management. Safe Transfusion of Blood and Blood Component Nurses are integral to the Blood Transfusion Process. Blood transfusion practice is the administration of a blood component or plasma-derived product to the patient, relative to the current requirements of national guidelines. Blood transfusion is concerned with ensuring that at a time when transfusion is clinically indicated, the patient receives the correct blood safely. Nurses have a responsibility to provide the highest standard of care and all patients have the right to expect this. Nurses are often involved in pre-transfusion sampling, provision of patient information, requesting blood from laboratory, collecting blood, administration of the transfusion and monitoring the patient’s responses during and after the transfusion event. As practitioners they are personally accountable for their practice and for ensuring that it is based on sound evidence to minimize the risk to which patients are exposed. Current emphasis in health care requires practice to be evidence-based rather than based on ritual or tradition. (Wilkinson, 2001). Blood is a body fluid in humans and other animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells. In vertebrates, it is composed of blood cells suspended in blood plasma. A blood transfusion is a safe, common procedure in which blood is given to you through an intravenous (IV) line in one of your blood vessels. Blood transfusions are done to replace blood lost during surgery or due to a serious injury. 196 Hospital Nursing Service Administration Manual

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Safety in Health Care Good Practice in Blood Transfusion Procedure Rationale Ensure availability of competent and trained staff. Explain to the patient and family the reasons for the transfusion and secure valid consent. . Provide supporting written information and answer questions. Ensure that the patient is wearing a correctly completed identity wrist band. Check the blood component that has been prescribed and the correct documentation. See to it that all required equipment is available, functional and suitable for the procedure. Ensure that the cannula intended for administration of the component is patent. Ensure correct blood compatibility documentation. Confirm that the blood component is for the intended patient. Take all equipment and documentation to the patient bedside. Ask the patient to state full name and date of birth. Compare verbal identifiers with identity wrist band. Check the blood component expiry date and quality in particular looking for signs of leakage or deterioration. Check that the details on the label attached to the bag are identical to those of the original bag label, that is, serial number and blood group. Perform pre-transfusion observation of temperature, pulse and blood pressure and document on the observation chart or transfusion record. Run the blood component at the prescribed rate. Document the exact time of blood transfusion. Ensure that the patient has a call bell and knows how to call for assistance in the event of any potentially related symptoms. To minimize delay and risk to the patient. To ensure that the patient understands the procedure To ensure positive identity. To minimize delay and risk to the patient and avoid wastage of blood To minimize delay and risk to the patient. To minimize delay and risk to the patient. To minimize delay and risk to the patient. To maximize patient safety and minimize wastage if an incorrect unit has been collected and is to be returned to the blood bank. To enable correct pre-transfusion checking procedure. To confirm patient identity. To confirm positive identifier. To ensure the blood meets any special requirements of the patient. To ensure that the correct compatibility label is attached to the bag. To establish baseline levels so that any potentially transfusion related deviations will be recognized. To ensure safety and well-being of the patient. To maintain accurate documentation label. To aid early recognition. 197 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Procedure Rationale Maintain visual observation of the patient for the first fifteen minutes. Repeat and document observations of TPR 15 minutes after commencement transfusion. Maintain additional observation according to policy. Continue transfusion at the correct rate until completed. If another unit is not required, disconnect and record the stop time. Repeat and document observation of temperature, pulse, respiration and blood pressure. To aid early recognition of a transfusion reaction. To aid early recognition of a transfusion reaction. To aid early recognition of a transfusion reaction. To maintain accurate documentation. To aid in recognition of transfusion reaction (Refer to Appendix S, National Voluntary Blood Services Program, Transfusion Standard Operating Procedures) 198 Hospital Nursing Service Administration Manual

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Risk Management 12 RISK MANAGEMENT Introduction Risks to patients, staff, and organizations are prevalent in healthcare. Thus, it is necessary for an organization to have qualified healthcare risk managers to assess, develop, implement, and monitor risk management plans with the goal of minimizing exposure. There are many priorities to a healthcare organization, such as finance, safety and most importantly, patient care. Risk managers are trained to handle various issues in multiple settings. The duties a risk manager undertakes are ultimately determined by the specific organization. These professionals typically work in the following areas of medical administration: Financing, insurance, and claims management Event and incident management Clinical research Psychological and human healthcare Emergency preparedness Risk is a potential threat or possibility that an action or event will adversely affect the ability to achieve desired objective. It is an event or condition that, if it occurs, could have a positive or negative effect on a project’s objectives. Risk Management is the process of identifying, assessing, responding to, monitoring, and reporting risks. This Risk Management Plan defines how risks associated with the project will be identified, analyzed, and managed. It outlines how risk management activities will be performed, recorded, and monitored throughout the lifecycle of the project and provides templates and practices for recording and prioritizing risks. Examples of Risks: Nosocomial Infection, Communication Failure, High Occupancy, Wrong Identification of patient, Chemical/ Radiation Exposure The role of the nurse in relation to Risk Management is to effectively recognize risk assessment tools and will be utilized, various measurements have been put in place to minimize the risk to patients who come into contact with health services in both primary and secondary care settings. 199 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Objectives e Provide safety of patients, and health care workers in their care in order to create a culture of safety. e Serves as with quality management for the hospital. e Strengthens decision-making process in the provision of patient care. e Focuses on clinical risks in connection with prevention, diagnosis, treatment and nursing care. e Provides a systematic, structured, prioritized and tailored to the needs of the individual organization. e Focuses on inter-professional and inter-disciplinary communication. In a hospital setting, risk management is complex. It involves identifying, assessing and averting risks in virtually every area of the hospital. It is the role of the nurse manager to perform risk management. She must conduct failure mode and effects analysis The safety culture describes the manner in which safety is organized in the context of patient care and reflects the attitudes, convictions, perceptions, values and conduct of management and other staff with respect to the safety of patients, staff and the organization itself. Safety culture must be promoted in the entire hospital and can be developed and is subject to a constant learning process. The health care workers identifies and evaluates risks as a means to decrease injury to patients, health care workers, and significant others within the hospital. Risk managers work proactively and reactively to either prevent incident or to minimize the damages of an event Importance of Risk Management Risk Management employs a number of systems to identify and provide notification of incidents or events that have occurred involving patients, visitors, staff, equipment, facilities or grounds which are likely to give rise:

1. To potential liability, affect the quality of patient care or affect safety in the hospital.
2. Early identification of such occurrences allows to immediately investigate the circumstances of the incident, and if necessary, institute corrective action to prevent similar occurrences in the future. To have clearly defined roles and responsibilities.
3. To improve patient safety through the adoption of a coordinated and multidisciplinary approach to the management of risk.
4. To encourage open and honest reporting of incidents through the use of a single incident reporting system.
5. To establish clear and effective communication that enables information sharing. Ww 200 Hospital Nursing Service Administration Manual

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Risk Management 7. To foster an open culture that allows organization wide learning. 8. To ensure that risks are identified, assessed, and prioritized. Risk assessment is linked to the practice of risk management, whereby a mutually agreed plan, aimed at reducing identified risks, is negotiated with the individual concerned. The plan incorporates specific therapeutic strategies and is collaborative, interactive and dynamic process rather than something that is done to the person. Risk assessment provides useful information when delivering care plan. It also has an impact on psychotherapeutic issues such as engagement with the person and concordance with treatment. Risk cannot be eliminated as there is no such thing as completely risk-free situations. Outcomes are not easily predicted. The nursing goal is the minimization of risk and prevention of harm or further harm. Strategies of Risk Management e Transferring the risk to another party e Avoiding the risk e Reducing the negative effect of the risk e Accepting some or all of the consequences of a particular risk The duties under a Risk Management job description include the following: e Designing and implementing an overall risk management process for the organization, which includes an analysis of the financial impact on_ the company when risks occur e Performing a risk assessment: Analyzing current risks and identifying potential risks that are affecting the company e Performing a risk evaluation: Evaluating the company’s previous handling of risks, and comparing potential risks with criteria set out by the company such as costs and legal requirements e Establishing the level of risk, the company is willing to take Preparing risk management and insurance budgets e Risk reporting tailored to the relevant audience. (Educating the board of directors about the most significant risks to the business; ensuring business heads understand the risks that might affect their departments; ensuring individuals understand their own accountability for individual risks) Explaining the external risk posed by corporate governance to stakeholders Creating continuity plans to limit risks Implementing health and safety measures, and purchasing insurance Conducting policy and compliance audits, which will include liaising with internal and external auditors Maintaining records of insurance policies and claims Reviewing any new major contracts or internal business proposals Building risk awareness amongst staff by providing support and training within the company 201 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Clinical Risk Management It comprises the totality of the strategies, structures, processes, methods, instruments and activities used in prevention, diagnosis, therapy and nursing care, that support staff at all levels, functions and professions in recognizing, analyzing, assessing and handling risks in patient care, so that the safety of patients, of those involved in their care and the organization itself is increased. Clinical risk management specifically is concerned with improving the quality and safety of health care services by identifying the circumstances and opportunities that put patient at risk of harm and action to prevent or control those risk. Categories of Risk

1. Patient care-related risks e Risk associated with clinical practice — direct patient care and incident reduction. e Indirect patient care — security, personal, infection control,management of buildings and the environment. e Direct association with patient care e Consequences of inappropriate or incorrectly performed medical treatments e Confidentiality and appropriate release of information e Protection from abuse, neglect and assault e Was patient informed of risks? e Nondiscriminatory treatment
2. Medical staff - related risks e Was patient properly managed? e Do we have adequately trained staff? e Occupational safety and health, - working practice, legislative requirements training and education
3. Employee - related risks e Maintaining a safe environment — Employee Health Policy e Reducing risk of occupational illness and injury e Providing for the treatment and compensation of workers for work - related illnesses or injuries e Providing a healthy atmosphere for workers e Promoting increase work production by improving the health of the worker e Promoting safety against health hazards encountered in the work environment e Promoting full functional capacity of the worker
4. Property - related risks e Protect assets from losses due to fires, floods, etc. e Paper and/or electronic records—patient, business and financial - protected from damage or destruction e Bonding and insurance to protect facility from losses 202 Hospital Nursing Service Administration Manual

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Risk Management Financial risks Organizational risks Organizational risk refers claims management, communication and information technology development. Nw Examples of Risk: | Nosocomial Infection, Communication Failure, High Occupancy, Wrong identification of patient, Chemical/radiation exposure Four (4) Steps Process to Manage Clinical Risks e Identify the risk e Assess the frequency and severity of the risk e Reduce or eliminate the risk e Cost the risk Clinical Risk Management Activities e incident monitoring sentinel events the role of complaints in improving care complaints and concerns where the individual is responsible coronial investigations Principles of Risk Management The nurse manager focuses on the five (5) basic principles of risk management as follows: 1. Avoids risk and identify appropriate strategies wherein it used to avoid the risk whenever possible, if a risk cannot be eliminated, the nurse manager shall intervene. 2. Identifies the risks and assess the risk and find out the nature of the risk and who is involved. 3. Analyses the risk and to examine how these risks can occur and what are the consequences of the risks to occur. 4. Evaluates risks and determines how the risk can be decreased or eliminated or zero risk. This is followed by documentation process and response or outcomes. 5. Manages the risks by determining who is responsible for taking actions, when and how will it be monitored or controlled. 203 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care RISK MARAGEMERT Figure 12.1Risk Management Essentials for Risk Management Program e An appointed Risk Manager who will be supported by the different segments of the Governing board, CEO, medical staff, and other segments of the hospital community. e A Risk Manager who will make the rounds and meet department heads to acquaint each of them with his/her responsibilities. e Implement the following six (6) step program with the cooperation of the Risk Management Committee to ensure that the hospital is doing all it can in the area of risk management: fe) O° Identification of situations in the hospital that could produce an incident that would result in financial loss. Evaluation of incident reports for at least six (6) months, and comparing available data on incidents in other hospitals to be able to identify those situations in the hospital that are likely to yield an incident. Elimination of needlessly dangerous procedures that are performed in the premises, sale of equipment that can result in product liability suits. Reduction of risks so that the hospital can feel comfortable in instituting an internally-funded and operated insurance mechanism. Transfer of liability by having “hold harmless” agreements with drug and equipment manufacturers. Insurance coverage through the best option among the commercial, captive, and self-insurance by itself or in a combination to meet the needs of the hospital in the most reliable and cost-effective manner. 204 Hospital Nursing Service Administration Manual

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Risk Management An Integral Part of the Risk Management Program In-hospital grievance or complaint mechanism. Continuous collection of data with respect to negative healthcare outcomes. Medical care evaluation mechanism. Educational programs for hospital staff personnel engaged in patient care activities. e Continual refinement or risk management procedures and make them an integral part of the JCAH (Joint Commission on Accreditation of Hospitals) standards (International Journal of Innovation, Management and Technology, Risk Management in Hospitals, 2012). The Five (5) Risks Management Process Establish the Context Identify the risk Analyze the risk Treat the risk Evaluate the risk iy 92 IDS In a health care facility such as a hospital, communication are consultative meetings must be in place. Risk Management Process Step 1. Establish the Context It is essential that the context of risk must be clearly understood. There should be definition of relationship between the stakeholders and the environment that it operates, so that boundaries in dealing with the risk are clear. Strategic context are the environment within which the hospital operates. The organizational context refers to the objectives, core activities and operation. Step 2. Identify the risk The primary aim of this step is to identify what could go wrong and what are the consequences of it occurring. Frequently asked questions are: a. What can happen? List risks, incidents or accidents that might happen by systematically working through each competition, activity, or stage of an event to identify what might happen at each stage. b. How and why it can happen? List the possible causes and scenario or description of the risk, incident or accident. c. What is the likelihood of them happening? d. What will be the consequences if they do happen? 205 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care f Establish the Context : Step 5 Communication : and Treat the Risk <> Step3 Consultation Analyze the risk ae we Identify the risk hore we : Evaluate the risk nl Figure 12.2 Risk Management Process Physical risks may take in the form of personal injuries, sentinel events that can harm patients in the hospital. Ethical risks may involve assets of the hospital such as theft to properties of the hospital. Legal risks of nurses or doctors performing malpractice and negligence. Step 3. Analyze the Risks The analysis of identified risk likelihood and consequences are essential. These are potential risks and levels of risks are analyzed. The risk evaluation consists of comparison of the level of risks found in the analysis. However, if the analysis of risk is low, these are considered minimal but should be monitored and periodically reviewed to ensure they are set as an acceptable level. 206 Hospital Nursing Service Administration Manual

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Risk Management The criteria for evaluating the risks in a health care facility. Table 12.1Likelihood Scale Question — What is the likelihood of the risk event occurring? Ratin LIKELIHOOD 8 The potential for problems to occur in a year 5 ALMOST CERTAIN: will probably occur, could occur several times per year 4 LIKELY: high probability, likely to arise once per year 3 POSSIBLE: reasonable likelihood that it may arise over a five-year period 2 UNLIKELY: plausible, could occur over a five to ten year period 1 RARE: very unlikely but not impossible, unlikely over a ten year period Table 12.2. Loss or damage impact scale Question: What is the loss or damage impact if the risk event occurred (severity?) se PO AL IMPA : c O C © DIC CS 0 5 CATASTROPHIC: most objectives may not be achieved, or several severely affected 4 MAJOR: most objectives threatened, or one severely affected 3 MODERATE: some objectives affected, considerable effort to rectify i.e. sports injury — requires medical attention and has some impact on participation in sports and/or other activity 2 MINOR: easily remedied, with some effort the objectives can be achieved i.e. sport injury requires first aid treatment and prevents immediate participation in sport and/or other activity 1 NEGLIGIBLE: very small impact, rectified by normal processes i.e. sport injury but does not prevent participation 207 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Risk Priority The risk priority scale determines the nature of the risk and the action required. They are indicators to assist in the decision making of what action is warranted for the risks. Table 12.3. Risk Priority Scale Question: What is the risk priority? IMPACT 5 4 3 2 1 Catastrophic Major Moderate Minor Negligible Major Major (2) (2) @) Major | Medium Minor (2) GB) (4) Major Medium Minor Possible (2) i) (4) Medium Minor Minor (3) | (4) (4) Minor Minor Minor (4) (4) (4) » | Extreme risks that are likely to arise < = requiring urgent attention 2 have potetially serious consequences Major risks that are likely to arise and Hee potentially ¢ serious consequences requiring urgent attention or investigation Medium Medium risks that are Hoy a arise or have serious consequences Fequiring attention’ Minor Minor risks aaa low consequences that may ze ETT by routine procedures Step 4. Treat the risks. Risk treatment involves identifying the range of options for treating the risk, evaluating those options, preparing the risk treatment plans and implementing those plans. It is about considering the options for treatment and selecting the most appropriate method to achieve the desired outcome. 208 Hospital Nursing Service Administration Manual

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Risk Management Options for treatment need to be proportionate to the significance of the risk, and the cost of treatment commensurate with the potential benefits of treatment. Step 5 - Evaluate the risks. According to the standard, treatment options include: Accepting the risk — for example most people would consider minor injuries in participating in the sporting activity as being an inherent risk. Avoiding the risk is about your club deciding either not to proceed with an activity, or choosing an alternate activity with acceptable risk which meets the objects of your club. For example, a cricket club wishing to raise funds may decide that a rock climbing competition without a properly trained and accredited instructor, equipment etc., may decide a safer way of raising funds. e Reducing the risk likelihood or consequences or both is commonly practiced treatment of a risk within sport, For example use of mouth guards for players in some sports i.e. contact sports. e Transferring the risk in full or in part, will generally occur through contracts or notices. For example your insurance contract is perhaps the most commonly used risk transfer form. Other examples include lease agreements, waivers, disclaimers, tickets, and warning signs. e Retaining the risk is knowing that the risk treatment is not about risk elimination, rather it is about acknowledging the risk as an important part of the sport activity and some must be retained because of the inherent nature of the sport activity. It is important to consider the level of risk which is inherent and acceptable. e Financing the risk means the club funding the consequences of risk, i.e. providing funds to cover the costs of implementing the risk treatment. Most community non-profit sport clubs would not consider this option. Risk Identification e Notifications from reporting and learning systems, especially the Critical Incident Reporting System (CIRS) e Events that have caused harm to patients e Liability cases e Occupational accidents, e Complaints e External risks or instances of harm that have been made public e National and international recommendations for action on patient safety e Survey results e Statistics on complications e Results of medical and nursing inspections 209 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care i v : Step 1. Establish the context 5 ere © Define the scope of of nquiryobjectives: In what _— SRS UD SE —p> activity, decision, project, program, issue requires analysis © Identifyrelevant stakehoWers&reas inwlved or itmpacted

Risk Assessment ® Intemalanddr extemal environmentAactors 2

& ¥ Step 2 Identify the risk: — S| Identity ‘assess @ |*

| Riskidentification |< 2 fe What could happen? = = © Howand whee it could happen? 3 ow i Why it could happen? 3s 3 | What isthe impact or potential impact? = af = oS : : |_| | Step 3. Analyze the risk: sa Risk analysis DD) | Identifythe causes, contributing factors and actual 2 = or potential consequences aj © |°@ Identitycunent or existng controls J “= so[e Assessthe likelihood & impact/consequence to = 5 determine the nsk rating = ¥ = : : = Step 4. Evaluate the tisk: &

a Risk evaiuation aaa Id @ |; i thle orunacceptahk? 3 the risk need treatment orfurtheraction? @ Do the opportunites outweigh the threats? ¥ Step 5. Treat the risk:

z

© lf existing controls are nadequate, dentifyfuther m=} = Risktieatmient

|}q-=—=——= treatment options

© Devise a treatment plan e Seek endorsement & supporttor treatment © Determine the residual tisk rating once the risk is treated a Figure 12.3 Risk Management Steps (Adopted from The University of Adelaide. “Risk Management Handbook”) 210 Hospital Nursing Service Administration Manual

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Risk Management Scope of the Risk Management 1. Ww Enterprise Risk Management (ERM): Comprehensive risk management of the organization from top to down including financial and business viability. Patient care (Clinical) Medical staff (Such as: credentialing, privileging, job description, employee insurance, trainings, medical coverage) Non-medical staff (Such as: job description, training, medical coverage) Financial (Budgeting, cost-benefit and cost-effectiveness analysis, insurance coverage) Managerial (Such as: organogram, job descriptions, delegation of work) Project risk management (Such as: scope, time, cost, human resources, operational, procedural, technical, natural and political) Facility Management and safety (Such as: building safety, security of the facility, hazardous materials and waste disposals (HAZMAT), emergencies internal and external, fire safety, medical equipment maintenance plan and maintenance plan for each of the utility system.) Figure 12.4. Risk Management Principles An incomplete or incorrect incident report can impede the detection process. It is recommended that the incident report should: 1. Fully describe exactly what transcribed. Be simple and practical in format and take the least amount of time and effort to complete. Contain the name, address, age, and condition of the individual involved, along with exact location, time, date, and description of the occurrence. Have a physician’s examination date. Include checklist or questions to remind the reporter to include such items as bedrail status, reason for hospitalization, description of those involved, witnesses, and extent of out-of-bed privileges. (/nternational Journal of Innovation, Management and Technology, Risk Management in Hospitals, 2012) 211 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Risk Potential e Severity. The seriousness of the effect of potential failure mode. Reduction can only occur as a result of design change. Severely Evaluation Criteria Effect Criteria: Severity of Effect Ranking Very High Very high severity ranking, affects life of 5 people,involves non-compliance w/ gov’t regulation High Can lead to disability of people, customer 4 complaint with legal implication Moderate Customer experience discomfort, hospitalized, 3 customer complaint Low Customer experiences some dissatisfaction 2 Very Low Effect not noticed by most customers, effect 1 noticed by discriminating customers. e¢ Occurrence.The likelihood that a specific cause/mechanism of failure will occur; Reduced by design change. Probability FAILURE ranking Possible Rate Failure . Failure is almost

1in2 : Ware ie Very High inevitable 1in3 5 High Repeated Failures 1 are 4 8 P 1 in 20 . . 1 in 80 Moderate Occasional Failures 1 in 400 3 Low Relatively Few Failures 1 in 2000 2 SSS Remote Failure is Unlikely <in 15000 1 212 Hospital Nursing Service Administration Manual

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Risk Management e Detection Ability of a current design control to identify a potential cause Detection Criteria : Likelihood of Detection by Ranking Process Control Remote No known control (S) available to detect failure mode. Remote likelihood current 5 control(s) will detect failure mode Low Low likelihood current control(s) will detect failure mode 4 Moderate Moderate likelihood current control(s) will detect failure mode 3 High High likelihood current control(s) will detect failure mode 2 Almost Current control(s) almost certain to detect Certain the failure mode. Reliable detection 1 controls are known with similar processes e Risk Priority Number (RPN) RPN = Severity X Occurrence X Detection This is a guide to rank design concern. The Lower rate is better. Special attention should be given if it is high. Roles of Nursing Leaders in Risk Management The nurse manager ultimately is responsible and accountable for inclusion of appropriate risk management strategies with strategies to enhance and maintain quality of care. ... "Doing more with less," raises several critical risk management issues. The critical risk management issues include the issue on delegation. Essentials of Risk Management Program Following are the basic essentials of the risk management program in a hospital:

1. Appointment of a Risk Manager who will have the support of the governing board, CEO, medical staff, and other segments of the hospital community.
2. Risk Manager to make the rounds and meet department heads to acquaint each of them with his/her responsibilities.

Implement the following six-step program with the cooperation of the Risk Management Committee to ensure that the hospital is doing all it can in the area of risk management: a. Identification of situations in the hospital that could produce an incident that would result in financial loss. 28 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care b. Evaluation of incident reports for at least six months and comparing available data on incidents in other hospitals to be able to identify those situations in the hospital that are likely to yield an incident. c. Elimination of needlessly dangerous procedures that are performed on the premises, sale of equipment that can result in product liability suits. d. Reduction of risks so that the hospital can feel comfortable in instituting an internally funded and operated insurance mechanism. e. Transfer of liability by having "hold harmless" agreement with drug and equipment manufacturers. f. Insurance coverage through the best option among the commercial, captive, and self-insurance by itself or in a combination to meet the needs of the hospital in the most reliable and cost-effective manner. Furthermore, the hospital will have the following components as an integral part of their risk management program 1. In-hospital grievance or complaint mechanism. 2. Continuous collection of data with respect to negative healthcare outcomes. 3. Educational programs for hospital's staff personnel engaged in patient care activities. 4. Continual refinement of risk management procedures and make them an integral part of the standards. It should be stressed that the key to a successful risk management program is its loss control program. All necessary steps should be taken to have an effective loss control program through institutional commitment, documentation, and education, developing a functional organizational model, improving communications, anc continuing evaluation. Incident reporting process is designed to accomplish the following tasks: 1. Identifying and detecting risks. 2. Assigning values to risks. 3. Anticipating losses. 4. Deciding upon objective steps to minimize the impact on the patient and the hospital. An incomplete or incorrect incident report can impede the detection process. It is recommended that the incident report should:

1. Fully describe exactly what transpired.
2. Be simple and practical in format and take the least amount of time and effort to complete.
3. Contain the name, address, age, and condition of the individual involved, along with exact location, time, date, and description of the occurrence.
4. Have physician's examination data.
5. Include checklist or questions to remind the reporter to include such items as bedrail status, reason for hospitalization, description of those involved, witnesses, and extent of out-of-bed privileges. 214 Hospital Nursing Service Administration Manual

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Risk Management Risk Management Committee It is recognized that committee structure is essential for the proper and effective functioning of the risk management program. The Assistant Administrator for Quality Control will chair the Risk Management Committee which will have representatives from the following departments: 1. Quality Assurance 2. Blood Bank 3. Medical Audit 4. Infection Control 5. Safety and Security 6. Accreditation 7. Education 8. Physicians /Nurses 9. Legal Counsel 10. Tissue Committee 11. Professional Liability Committee 12. Professional Practices Committee 13. Medical Discipline 14. Medical—Legal Committee 15. Antibiotic Use 16. Therapeutics / Pharmacy 17. Medical Records 18. Utilization Review Committee The purpose of the Risk Management Committee will be to assist the Risk Manager in fulfilling the responsibilities of the position to minimize injuries to patients, visitors, and employees, and financial loss to the hospital. Strengthening the Risk Management Program In view of the rapid changes in all facets of the health care industry, there is a need to continually strengthen both monitoring and evaluation of the risk management program. Following are some of the needed areas of strengthening: 1. Continuing education of staff and responsible key persons. 2. Monitoring and evaluation of the integrated programs. 3. Communication with peers at local, regional, and national organizations in order to improve the program at the hospital. 4. Discovering situations that present potential for accidents. 5. Availability of sophisticated data on past occurrences. 6. Identifying areas of high risk in the hospital. 7. Development of an incident report form to meet the contemporary needs. 8. Requiring the staff to file incident reports immediately after incidents have taken place. 9. Reporting physician and nurse related incidents. 215 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 10. Monitoring and improving quality of care provided by physicians and other providers because increasing numbers of claims are holding hospitals liable for everything that occurs within their hospital premises. 11. Continuing support of all segments of the hospital community. 12. Statistical data from both internal and external sources. 13. Reduce the level of risk sufficiently so that the hospital can assume that risk itself through the less expensive self-insurance. Training and Awareness among Patients, Families and Non-Medical Personnel It is important to create awareness amongst staff as well as patients, families and non- medical personnel regarding safety rules and regulations applicable to the respective countries. They should be informed about various law and enactments. The need for training and awareness is not limited to hospital-based sites. It also applies to leased settings in which healthcare organization employees provide ambulatory health care services, but the building owner furnishes the housekeeping staff. Risk management has become an integral part of hospital administration. However, the needed attention to the concept and process of risk management in the developing countries is yet to be given. Since we are living in a global village and with advances in communication technology, the day is not far when patients will initiate law suits against the healthcare providers and hospitals for medical malpractice and negligence threatening patient safety. It is recommended that hospitals give serious consideration to implementing and /or strengthening risk management programs to protect their assets and minimize financial losses. How to format your risk management plan Your risk management plan needs to be accessible to management, counsel, contractors, consultants, caregivers, and hospital staff. To get buy-in, you may want to run your plan by your organization’s board of directors for approval and then bring staff on board. Recommendations e Implement regular, specific training program e Making sure patients understand how to take their medicine and why they need to do it can go a long way toward increasing medication adherence. e In Secrets of the Best-Run Practices, author Judy Capko emphasizes what she calls “commonsense risk management.” The first part of commonsense risk management, Capko argues, is putting effort toward making sure physicians have a good relationship with their patients. After all, “People are more than a little reluctant to sue their friends or people they really like, regardless of the nature of the suit,” Capko writes. 216 Hospital Nursing Service Administration Manual

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Risk Management I. Create a Culture of accountability Organizations establish cultures that implement evidence-based best practices, learn from past mistakes, and provide constructive feedback instead of just offering blame and punishment. You want to encourage staff members to communicate about risks with each other and with management, not be afraid of punishment. Providing counseling services for those working with patients, and conducting competency assessments. 2. Keep up to date on the research 3. Keep up to date on regulations - Someone on your team needs to stay familiar with regulations and directives. 4. Consider hiring help - You might want to consider hiring a qualified healthcare risk manager to further minimize unnecessary exposure. They can help you develop and implement risk management plans and assess and monitor existing ones. A risk manager can also handle claims management, which encompasses tasks like identifying which adverse events are likely to become claims before they do, investigating adverse events and notifying your defense counsel and/or liability insurance company reps of potential lawsuits. They can also assist defense counsel by setting up depositions, providing relevant information, and helping to implement alternative dispute-resolution tactics. The Risk Management Plan is created by the project manager in the Planning Phase of the Centers for Disease Control(CDC) Unified Process and is monitored and updated throughout the project. The intended audience of this document is the project team, project sponsorand management. Analysis of risk events that have been prioritized using the qualitative risk analysis process and their effect on project activities will be estimated, a numerical rating applied to each risk based on this analysis, and then documented in this section of the risk management plan. Risk Response Planning Each major risk (those falling in the Red & Yellow zones) will be assigned to a project team member for monitoring purposes to ensure that the risk will not “fall through the cracks”. 217 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care For each major risk, one of the following approaches will be selected to address it: e Avoid — Eliminate the threat by eliminating the cause e Mitigate — Identify ways to reduce the probability or the impact of the risk e Accept — Nothing will be done e Transfer — Make another party responsible for the risk (buy insurance, outsourcing, etc.) For each risk that will be mitigated, the project team will identify ways to prevent the risk from occurring or reduce its impact or probability of occurring. This may include prototyping, adding tasks to the project schedule, adding resources, etc. For each major risk that is to be mitigated or that is accepted, a course of action will be outlined in the event that the risk does materialize in order to minimize its impact. Risk Monitoring, Controlling, and Reporting The level of risk on a project will be tracked, monitored and reported throughout the project lifecycle. A “Top 10 Risk List” will be maintained by the project team and will be reported as a component of the project status reporting process for this project. All project change requests will be analyzed for their possible impact to the project risks. Management will be notified of important changes to risk status as a component to the Executive Project Status Report. Tools and Practices A Risk Log will be maintained by the project manager and will be reviewed as a standing agenda item for project team meetings. Sample of Ten (10) Top Risk List This Last Weeks Risk Risk Resolution Week Week | on List Progress To get an idea of how the old system was designed. Second 1 7 1 Unclear design version of Safety Data requirements. Sheet (SDS) document will have more detail on the design of the project. 218 Hospital Nursing Service Administration Manual

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Risk Management This Last Weeks Risk Risk Resolution Week Week | on List Progress Considering setting up Set up remote access to local copies of the SQL server. server on our local machines. N ' oy Milestones are set up to help us gauge our progress, and give us short term goals. Multiple releases will help to speed up the development of the project. Unachievable schedule. ud ' ra We will develop a user interface prototype to gather high quality requirements. Staged delivery approach will be used to provide the ability to change features if needed. 4

1 Creeping requirements. We are developing a Released software has low | quality assurance plan quality. | to help ensure a quality | product. nN ' We will develop a user interface prototype to assure users will accept Software does not meet 6

1 ' the software, to help us user's needs. . get an idea as to some of the functionality of the product. We try to use our documentation as a guide as to what needs to be accomplished, and then try to evenly spread the work amongst all of the team members. Unable to decide how to 7

1 divide work among team members. SDS document should provide a layout as to how each part should be integrated with the other part in the product. Unable to integrate all of 8

1 the parts developed separately. 219 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care This Last Weeks Risk Risk Resolution Week Week | on List s Progress s , Meeting times have Insufficient time to meet & 9

1 been set up on Monday together as a team. : and Friday. We should assign people to each document and have No updates made to them be responsible for documentation. updating that document. Personal logs also need to be kept up-to-date. 10

1 Primary responsibilities of leadership is to ensure a successful Quality Risk Management (QRM). Ben Franklin said “an ounce of prevention is worth a pound of cure” How this translate to Quality Risk Management? Company leaders must invest in, and be accountable for risk management programs. Their objective should be proactively manage risk, rather than solving issues as they occur, potentially resulting in major implications to business. e “Walking the walk” - Building a proactive, risk-conscious quality culture throughout all levels of the organization e Designing Quality Risk Management program sponsorship, organizational structure and governance to allow for program realization e Approving quality policies, documents, risk rating criteria, and risk tolerance thresholds based on their consistency with QRM principles and quality objectives e Ensuring the deliverables of the QRM program provide information that can be easily understood and used by leaders for decision-making e “Talking the talk” — Discuss risk during decision making and request risk information when preparing for a company decision e Investing in a company-wide information technology tool/software solution that greatly improves the ability to conduct and consolidate risk assessments and enable risk communication across the organization e Considering risks with regard to the company strategic framework and when building business objectives and goals e Establishing a risk communication plan to define how and when risks are communicated, both within the company and to external stakeholders Failure Mode and Effect Analysis (FMEA) Failure Modes and Effects Analysis (FMEA) is a technique that evaluates and identifies and eliminates possible failures, issues and errors related to a system, design, process. FMEA looks at the process of patient care and takes a multidisciplinary team to look at the process from a Quality improvements. 220 Hospital Nursing Service Administration Manual

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Risk Management FMEA looks at the system of care and utilizes a multidisciplinary approach toevaluate the process from a quality improvement point of view. This process can be utilized to look at different processes which are measurable. Measures that are in place must be clear and information that is objective related to how effective the process. According to the Joint Commission it requires all practitioners must be accredited and take an active role in risk management to identify and predetermine weaknesses within their practice and to initiate change to decrease patient injuries or death. Failure Modes and Effects Analysis is an approach that evaluates processes to point out which interventions might fail, and takes a proactive approach to evaluate and make revisions as needed. Failure Modes and Effects Analysis are almost the same as a root cause analysis. The process is a group effort from nurses, doctors, pharmacists and other ancillary staff including management and usually from each unit where the sentinel event or safety issue happened. Each issue is broken down in to sections. Failure Mode and Effects Analysis (FMEA) is a structured approach to discovering potential failures that may exist within the design of a product or process. Failure modes are the ways in which a process can fail. Effects are the ways that these failures can lead to waste, defects or harmful outcomes for the customer. Failure Mode and Effects Analysis is designed to identify, prioritize and limit these failure modes. Importance FMEA is to take actions to eliminate or reduce failures, starting with the highest- priority ones. Failure modes and effects analysis also documents current knowledge and actions about the risks of failures, for use in continuous improvement. FMEA is used during design to prevent failures. Types of FMEAS (Failure Mode Effect Analysis) e System FMEA used to analyze systems and subsystems in the early concept and design stage. It includes the interactions between systems and elements of the system. used to analyze products and service before they are released to manufacturing or implementation of e Design FMEA service. e Process FMEA

used to analyze manufacturing and assembly processes. e Service FMEA

used to analyze services before they reach the customer Benefits of FMEA o Captures the collective knowledge of a team o Improves the quality, reliability, and safety of the process o Logical, structured process for identifying process areas of concern 221 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Reduces process development time, cost Documents and tracks risk reduction activities Helps to identify critical-to-quality characteristics Provides historical records; establishes baseline Helps increase customer satisfaction and safety oo0°0 High-Level Management Roles and Responsibilities The importance of broad support from management in implementing an effective FMEA process cannot be overstated Champion the subject of FMEA with management and employees. Provide agreement on FMEA strategy and support needed resources. Implement an effective FMEA training program. Define roles and responsibilities for all FMEA participants, and integrate with employee work instructions. 222 Hospital Nursing Service Administration Manual

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Nursing Information Management System 13 NURSING INFORMATION MANAGEMENT SYSTEM Introduction Recording assessment data using a computer keyboard allows just as much caring communication between nurse and clients as writing it down on a form. The critical factor is not the method of recording but the interpersonal skills and motivation of the nurse. The nursing profession is at last beginning to appreciate the role which the new technology can have in improving the service provided to patients. Only by taking an active role now in the implementation of computers to clinical practice can nurses maintain control of their own professional contribution to the large complex systems at present being implemented in many healthcare settings. Knowledge-based systems are set to become a major component in the nurse’s ability to take on this role. Nursing Information Management System is a system approach that integrates data collection, processing, reporting and use of the information necessary for improving health service effectiveness and efficiency through better management at all levels of nursing health services. Importance of Nursing Information Management 1. Provide quick access to useful and reliable clinical information for decision about patient care management 2. Support the management in the decision-making 3. Promote consistent nursing records, as it is directed to the nursing practices and processes 4. Help nurses to use data more effectively while managing the nursing activities, that will allow improvement of patient’s health status Increase efficiency for recording observation and doing care plans 6. Analyze data applied for management information system and facilitate communication about the patient among healthcare providers an Information System “A set of interrelated components working together to gather, retrieve, process, store, and disseminate information to support the activities of health system planning, control, coordination, and decision-making, both in management and _ service delivery” Jack Smith, in: Health Management Information Systems — a handbook for decision makers. (Oxford University Press, 2000) 223 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care An information system is integrated and co-ordinate network of components, which combine together to convert data into information. Five (5) Components of Information System e Hardware consists of input/output device, processor, operating-system and media devices. e Software consists of various programs and procedures. e Database consists of data organized in the required structure. e Network consists of hubs, communication media and network devices. e People consist of device operators, network administrators and system specialist. General Functions of an Information System e Files Are Easier to Access. Health information systems have revolutionized the way that doctors and health care professionals maintain patient information. These systems are electronic, so the days of hard files and loose papers are over. e More Controls. Staff must be authorized to access the health information system. Doctors may have permission to update, change and delete information from the electronic medical record. e Easy to Update. Health information systems let doctors create electronic medical records for their patients. Patient information can be pulled up for review at any time and copies can be made for the patient upon request. e Communication. Health information systems abet communication between multiple doctors or hospitals. According to Government Health IT, medical professionals must pay close attention to confidentiality issues, such as patient privacy and security safeguards to ensure unauthorized users cannot access the information. Benefits derived from Hospital Information System reduced cost capture of lost charges reduced length of stay reduced paper work improved communications personnel scheduling improved collections improved bed utilization reduced inventory improved management essential available patient data data base for planning and investigation fewer errors 224 Hospital Nursing Service Administration Manual

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Nursing Information Management System e instantaneous input and retrieval of clinical information from numerous remote site e improve quality patient care Doctors, nurses and other health professionals should use the Information System for: e better-informed decisions e alerts, protocols and guidelines e diagnostic and treatment support e clinical research e medical education, medical auditing for access to scholarly information Administrators and managers should use the Information System for: e executive decision support e outcome management e cost analysis e tracking quality initiatives multiple documents Hospital Information System A Hospital Information System (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals. In many implementations, it is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation. such as medical. administrative. financial. and legal issues and the corresponding processing of services. Importance of Hospital Information System 1. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries 2. Itis easy to use and eliminates errors caused by writing Gives perfect performance to pull up information from server or cloud sources 4. It can improve cause control, increase the timeliness and accuracy of patient care and administration information, increase service capacity and improve the quality of patient care we Computers can be applied in Nursing e Computers help with patient history, medical records and patient monitoring. e Computerized record systems can improve the usability of patient information’s because data from the chart can be rearranged to be useful to various health care professionals. e Physicians can enter their diagnosis, protocols and notes directly into the computer, saving nurses transcribing time. e The instruction can be printed out at the appropriate auxiliary department. Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Nurses can also record their notes directly into the computer and spend less time and energy accumulating and summarizing data to develop care plan. Standard screens with standard choices increase efficiency for recording observation and doing care plans. Nurses are made aware of changes that require their intervention quickly because information from the ancillary department can be sent automatically to the nursing station terminal. e The computer can sort and analyze data and facilitate communication about the patient among health care providers. e In addition to monitoring patients continuously and detecting changes, computers can analyze and interpret the data. Through computer monitoring, nurses can respond quickly to changes in patient’s condition. e Computers have many applications in management information system. They can be used for the patient classification system, supplies and material management, staff scheduling, policy and procedure changes and announcements, patient charges, budget information and management, personnel records, statistical reports, administrative reports, and memoranda. Integrated Hospital Operations and Management Program (IHOMP) The Integrated Hospital Operations and Management Program (IHOMP), formerly Hospital Epidemiology Program (HEP) was conceptualized in 1999 through the Health Sector Reforms Agenda, consistent with the Continuing Quality Improvement Program. It was implemented by DOH to selected LGUs and DOH hospitals through the Integrated Community Health Services Project (ICHSP). Mandate: A.O. No. 44-A s. 1999 “Guidelines for the implementation of the Integrated Hospital Operations and Management Program (IHOMP) within the Philippine Hospital System.” The Integrated Hospital Operations and Management Program (IHOMP), is a Program that ensures continuing quality improvement (CQI) of hospital services toward patient’s satisfaction. IHOMP anchors an information system that will result in a more cost-efficient and effective hospital operations and management, and ultimately better patient care for all Filipinos. It is envisioned that all Filipinos will have access to appropriate and excellent hospital care that is informed by a functional and integrated hospital information system. The IHOMP ensures the proper collection and utilization of accurate and reliable data for effective hospital management and quality care programs; well-informed citizens on the health care needs; patient safety in hospitals; accessible and affordable health care services for all Filipinos To improve hospital performance through sound and efficient clinical care and management systems with the end-view of providing quality health services. 226 Hospital Nursing Service Administration Manual

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Nursing Information Management System Specific Objectives for Hospitals I. wa 6. Provide modern Information System that facilitate efficient and effective hospital operations and management; Increase efficiency, transparency and accountability; Improve hospital planning & budgeting for hospital operations; Ensure rapid access to patient’s records during confinement; Facilitate efficient collection of accurate hospital data used in planning and decision-making; To facilitate immediate submission of Reports to stakeholders. Specific Objectives for DOH 1. To determine the cost of hospitalization with different diagnosis 2. To develop indicators of hospital case mix; and 3. To develop hospital performance standard Strategies Program Planning Assessment and Monitoring Capability Building Social Mobilization Logistics Support Hospital Operation Manuals Manual of Organization and Management of the Administrative and Finance Service for Hospitals Hospital Nursing Service Administration Manual Hospital Health Information Management Manual (Formerly Hospital Medical Record Management Manual) Manual for Medical Social Workers Hospital Pharmacy Management Manual Hospital Nutrition and Dietetics Service Management Manual Hospital Property and Supply Management Manual Manual of Standards and Guidelines on the Management of the Hospital Emergency Department Quality Management in Clinical Laboratories National Standards in Infection Control for Healthcare Facilities Integrated Hospital Operations and Management Information System (iHOMIS) HOMIS is a software used as a tool for hospitals to facilitate immediate collection of accurate hospital /patient data and immediate generation of Reports needed by stakeholders. Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care iHOMIS has three (3) Modules: e Module I includes the medical records, admitting section, social service and billing. e Module II includes the laboratory, radiology, pharmacy, OR and emergency room and clinical areas. e Module IT includes the financial and administrative service. Record It is a permanent written communication that documents information relevant to a client’s healthcare management, e.g., a client chart is a continuing account of client health care status and need It is a clinical, scientific, administrative and legal document relating to the nursing care given to the individual family or community. They are hospital administrative tools used in collecting data directed towards the attainment of the objective of its sections and department, and are the sources of cumulative and relevant information that may be used as basis for patient management and the effective planning of activities for training, research and decision making. They are valuable legal documents and so it should be handled carefully and properly accounted for. Sample of Records Administration Records for Grants/Contracts e Bid Documents Blueprints of Facilities Consent Forms - Adult and Minor Contracts - Purchase, Lease or Rental Endowment Fund Records Equipment Inventory Reports (Physical Inventories) General Ledgers Meeting Minutes Organization Charts and Listings Payroll Folders Personnel Folders Policies and Procedures Research Data Protocols (Drug Development and Human Subjects) Security Codes Technical System Documentation Transcripts eeeee#ee#eteeeeeeee8 8 6 228 Hospital Nursing Service Administration Manual

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Nursing Information Management System Records Management It is the systematic and effective control of records (both paper and electronic) throughout their life cycle from creation or receipt through to the time of their disposal. It aims to ensure that records are accurate and reliable, can be retrieved speedily and efficiently, and are kept for no longer than necessary. Importance of Records Management Records management is crucial to all organizations. Unless records are managed efficiently it is not possible to conduct business, to account for what has happened in the past, or to make decisions about the future. Records are a vital, corporate asset and are required: To provide evidence of actions and decisions. To support accountability and transparency. To comply with legal and regulatory obligations, including employment, contract and financial law, as well as the Data Protection Act and Freedom of Information Act. To support decision making. To protect the interests of staff, students and other stakeholders. Help to address complaints or legal processes, including requests from patients under subject access provisions of the Data Protection Act or other requests under the Freedom of Information Act. To support patient choice and control over treatment and services designed around patients. To support day-to-day business which underpin the delivery of care. To support evidence-based clinical practice. To assist clinical and other types of audits. To support sound administrative and managerial decision-making, as part of the knowledge-base for NHS services. To support improvements in clinical effectiveness through research and also to support archival functions by taking account of the historical importance of material and the needs of future research. Record-keeping procedures and processes should cover all types of patient activity where data is collected onto relevant systems and paper-held records. Benefits of Records Management Saves time by ensuring that records can be found easily and quickly Saves space by preventing records from being kept longer than necessary Saves money by reducing storage costs and maintenance costs Improves efficiency by ensuring records are readily accessible Improves compliance by keeping records in line with legal and regulatory requirements 229 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Improves the quality of information, providing staff with access to accurate and reliable quality records security e Increases the security of confidential records e Supports business continuity and risk management e Records are managed efficiently and can be easily accessed and used for as long as they are required; e Records are stored as cost-effectively as possible and when no longer required they are disposed of in a timely and efficient manner; © Complies with all requirements concerning records and records management practices to ensure compliance with constitution; e Records of longer term value are identified and protected for historical and other research. Purposes of Records

1. Provides staff member, administrator, and other health team members with essential data for program planning and evaluation.

Serves as tools of communication between health workers, the family, and other development personnel. 3. Provides data to forecast the long-term changes for service improvement. Nursing Office Records For effective administration of the Nursing Service, the Chicf Nurse should provide complete and up to date records. The following should be available in the Office of the Chief Nurse: e Personal Record (Form 201). This includes a copy of the personal data, appointment, promotions, physical examination, performance rating, evaluation, references, achievement, staff and professional activities and confidential information. e Master Staffing Pattern. This is a daily assignment of the nursing personnel which will help the Chief Nurse visualize the coverage of all nursing units, serving as a guide and support for proposing additional positions in the Nursing Service. It contains the actual number of nursing staff on sick leave, on-the-job training and on study leave. e The Daily Census of Patients. This includes a detailed list of actual patients in the different in-patient and the total census for 24 hours. e Daily Time Records or Bundy Cards. These indicate the time each personnel reported to and from duty. e Nursing and Hospital Policies. All directives affecting the Nursing Service are compiled in a loose leaf manual which is available for reference. These may refer to policies, admissions, discharges, transfers for regulation, time 230 Hospital Nursing Service Administration Manual

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Nursing Information Management System and work schedules, charging of patients, etc. Directives are dated and signed by the sender. Manual of Procedure \s a set of standards operating procedures for carrying out oral/telephone orders for medications, errors in medication, omission of treatment, preventive measures, such as (use of side rails and restraints) arrangement of the patient’s clinical charts, transcribing of doctor’s orders. Minutes of the Nursing Service Meetings. Minutes of meetings within the Nursing Service Manual are kept on file for ready reference. Policies, rules and regulations are discussed for weakness of interpretation and implementation. Nursing Affiliation record (for training and teaching hospital). o The school college folder contains approved affiliation contract with the list of students including the date and time for affiliation and the clinical instructors. o Record of payments provides the number of students; date and length of affiliation; and payments each with corresponding receipt number and date such were paid. © Quarterly Report of Affiliation o Performance Evaluation Record of Affiliation Records of Staff Development Programs conducted o Outreach Program On-the job training Nursing Leadership and Management Training Continuing Education Program Record of Nursing Researches conducted Continuous Quality Improvement Program conducted by Nursing 0000 ° Importance of Recording and Reporting 1 a CRS N Measures, monitors and controls to enhance the workforce performance Improves communication among managers, subordinates, customers and other stakeholders Sets benchmark for quality improvement of services Measures, monitors and controls to enhance the workforce performance Improves communication among managers, subordinates, customers and other stakeholders Sets benchmark for quality improvement of services Ensures compliance to statutory, regulatory and other legal requirements Principles of Record Writing 1. Nurses should develop their own method of expression and form in record writing Records should be written clearly and appropriately Records should contain facts based on observation, conversation and action Select relevant facts and the recording should be neat, complete and uniform 231 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 5. 6. Records should be written immediately after an interview Records are confidential documents Nurses Responsibility for Record Keeping and Reporting AWN 22 Keep under safe custody of the nurse No individual sheet should be separated Not accessible to patients and visitors Strangers is not permitted to read records Records are not handed over to the legal advisors without written permission of the administration Handed carefully, not destroyed Identifies bio-data of the patients such as name, age, admission number, diagnosis, etc. Never sent outside the hospital without the written administrative permission Patient Verification Two identifiers: patient name and date of birth Compare ID band, consents, diagnostic images, and all other patient documentation related to the procedure Nursing Administrator’s Responsibility to Records Protection from loss Safeguarding its contents Completeness Responsibility for nurse notes Legal value of nurses notes Admission record Scientific value of the nurse notes Record of order carried out Individual Staff Record A separate set of record is needed for staff, giving details of their sickness and absences, their career and development activities and a personnel note. Administrative Records Treatments Admissions Equipment losses and replacements Personnel performance Other administrative records 232 Hospital Nursing Service Administration Manual

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Nursing Information Management System Characteristics of Good Recording and Reporting Accuracy Consciousness Thoroughness Up-to-date Organization Confidentiality Objectivity Administrative Purpose of Clinical Records Legal documents: poisoning, assault, rape, leaving against medical advice (HAMA/DAMA), burn etc. Research or statistics: rates Audit and nursing audit Quality of care Continuity of care Teaching purposes of students Diagnostic purposes: test reports Importance of Records in Hospital For the individual and family e Serve the history of the client e Assist in the continuity of care e Evidence to support if legal issues arise e Assess health needs, research and teaching For the Doctor Serve the guide for diagnoses, treatment, follow up and evaluation Indicate progress and continuity of care Self-evaluation of medical practice Protect doctor in legal issues Used for teaching and research For the Nurses Document nursing service rendered Planning and evaluation of service for future improvement Guide for professional growth Communication tool between nurse and other staff involved in the care Indicate plan for future 233 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care For Authorities e Statistical information Administrative control Future reference Evaluation of care in terms of quality, quantity and adequacy Help supervisor to evaluate service Guide staff and students Legal evidence of service rendered by each employee Provide justification of expenditure of funds Required Patients’ Data That Needs to be Documented e Admitting Area-E R/OPD o Admission date, time, and room/bed number of patients. o Mode of admission, such as; ambulatory, by wheelchair, by stretcher, ete. Vital signs: Blood Pressure (BP) level of consciousness; Pulse Rate (PR); Respiratory Rate (RR); Temperature; Height and Weight. Admission notes, the latest version of which is focus charting. The observed disposition of valuables endorsed for safekeeping. The Admitting physicians. Written orders and prescriptions of physicians. Medications given: date. time, dosage, route Specimen (s) obtained:

Type of specimen(s)

Time it was obtained

Time it was submitted to the laboratory with signature who submitted and received the specimen. This will prevent loss or misplacement of specimen o Status of patient during transfer to other patient areas. 00000 O° O° e In-Patient Areas o Time of doctor’s visit and all subsequent visits of the physician o Written orders of all physicians o Specimen(s) obtained:

Type of specimen(s)

Time it was obtained

Time it was sent to the laboratory o Reactions, Attitudes, Moods and Status of the Patient

Pertinent subjective observation

Complaints of pain

Discomfort or other attitudes

State of depression, worry, agitation, reaction to hospitalization or illness. 234 Hospital Nursing Service Administration Manual

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Nursing Information Management System o Objective observation

General Appearance/Changes on:

Respiration

Drainage

Condition of the skin

Edema, etc.

Attitudes/Observation for any signs of:

Depression

Worry

Agitation " Reaction towards hospitalization or * TllIness

Activity/Type of activity

Nurse’s observation

Position changes as to time

Response and tolerance to activity

Paralysis and degree of limitation of movement

Vital signs - Time checked and description of * Pulse Rate

Respiratory Rate

Cardiac Rate

Temperature

Blood Pressure

Level of Consciousness

Body weight and height taken on admission

Therapy and time instituted o Medications © Prescribed diet and appetite of the patient including allergies or idiosyncrasies o Transfer as to date, time and mode to and from any unit or department o Nursing Care Rendered

Nursing procedures

Comfort measures Health teachings

Evaluation of care o Completion of the day’s charting at midnight as to time, date, and calendar hospital date. o Use of black/blue ink for AM and PM shifts, red for night shift. Accidents, such as falling from bed, shall be reported to the immediate supervisor and recorded, indicating the time and condition of the patient. Reports are verbal or written informational work in a particular matter made with an intention to relay events, situations in a presentable manner for decision making. It can be compiled daily, weekly, monthly, quarterly and annually. Report summarizes the services of the nurse and/or the agency. These are based on records and registers 235 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care and so it is relevant for the nurses to maintain the records regarding their daily case and service load and activities. Thus the data can be obtained continuously and for a long period. It is a document that presents information in an organized format for a specific audience and purpose. Although summaries of reports may be delivered orally, complete reports are almost always in the form of written documents. Mandatory Reports Bi — Annual Reports to be submitted at HFDB (January to June and July to December) Consumption Report Inventory Report Daily 24hrs Report Sentinel Events Incident Reports Others Guidelines for Reporting The Chief Nurse shall prepare and submit Bi-Annual reports using the prescribed form. Bi-annual reports should be submitted to the Nursing Adviser in the Health Facility Development Bureau, (HFDB). The first report should reach the Central Office on or before January 15 and July 15 of the given year. Types of reports include: Memoranda Minutes Laboratory reports Book reports Progress reports Justification reports Compliance reports Annual reports and Policies and procedures Required Administrative Data

1. 24-hours report — daily census, admission, expired, transfer, sentinel events, discharge
2. Accomplishment Report — monthly
3. Consumption Report — monthly 236 Hospital Nursing Service Administration Manual

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Nursing Information Management System 4. Performance Commitment Review or Performance Appraisal Report — every six months 5. Bi-annual Accomplishment Reports 6. Project Procurement Management Plan (PPMP) Incident Reports The Nursing Service personnel should fill up incident reports when a problem in nursing care delivery has occurred. These reports are meant to be non-judgmental, factual reports of the problem and its consequences. The nurse should understand that filling up an incident report is not tantamount to blaming a fellow employee for no problem. More important, it should be made clear that filling up an incident report is not an admission of negligence. Incident reports are simply records of all events that are not part of routine medical care. The Nursing Service should promulgate lists of events whose occurrence requires the filing of an incident report. The staff must also be free to file a report even if the event does not appear on the list of mandatory reports. This allows the incident reports to be used as a way formally asking a question about a questionable procedure. The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discovered in litigation. Reports are prepared accounts of important activities of the Nursing Service within a particular period. Reports are either oral, taped or written exchanges of information between nurses / members of the health team. These include: e Change-of-Shift Reports is a system of communication aimed at transferring essential information and holistic care for patients. The purpose is to provide continuity of patient care for 24 hours. o Oral report — a pre-conference made prior to nursing rounds, done in the nursing conference room or nurses station. Essential information about the patient conditions or health problems, effects of nursing and medical measures to be reported to the incoming shift. o Nursing Rounds — These are made at the patient’s bedside. The patient care plan is discussed. The nurse can perform assessments, evaluate the patient’s progress and determine the interventions that best meet his/ her needs. e Telephone Report/Orders o Information given through telephone should be accurately transcribed by the receiving nurse in a written form especially if this pertains to medications. o Legal risks in telephone orders. These may be understood or misinterpreted by the receiving nurse. o Only in an extreme emergency and when no other physician is available 237 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Should a nurse receive telephone orders. o The nurse should note the date and time when the order was made, when he/ she wrote the order, name of physician making the order, then sign his / her name including designation. e Transfer Reports o Before a patient is transferred to another agency, proper coordination must first be made to ensure that the agency has the proper services and facilities needed by the patient. A transfer report accompanies the patient. Inter-agency Referral Form should be properly and completely filled up by the physician. o Patients may be transferred from one unit to another as their condition or case warrant it. The receiving unit is usually notified in advance about the transfer so that the unit or bed which the patient will occupy, including special equipment if needed, will be prepared. Important points to consider in making reports Reports, whether written or oral, must be up-to-date, clear, and concise. Channels of communication should be properly observed. Reports should be accomplished in forms adapted by the hospital. Reports should be factual and may include recommendation for action. Verbal reports made in an emergency situation should be confirmed in writing and duly signed by the person making the report. Nursing Documentation Nurses are required to make and keep records of their practice. As self- regulated professionals, nurses are accountable for ensuring that their documentation (whether using a paper-based or electronic system) is accurate and meets the Standards for Documentation, and the Standards of Practice. Documentation establishes accountability, promotes quality nursing care, facilitates communication among nurses and other healthcare providers, and conveys the contribution of nursing to health care. These standards explain the regulatory and legislative requirements for nursing documentation. To help nurses understand and apply the standards to their individual practice. Additionally, in order to uphold accreditation, healthcare facilities must meet the documentation standards. Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet 238 Hospital Nursing Service Administration Manual

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Nursing Information Management System legal and professional requirements, and one of the most significant components in nursing care. Purposes of Documentation e Communication.Recording is a method of communication that validates thecare provided to the client. It should clearly communicate allimportant information regarding the client. e Education.Health care students use the medical record as a tool to learn about the disease process, complications, medical surgical diagnosis and interventions. e Research. Rely on clients’ medical records as clinical data source to determine if clients meet the research criteria for study. e Legal and Practice Standards.Failure to document is a key factor because the medical record is a legal document, and in case of lawsuit, the records serves as a description of exactly what happened to the client. e Professional Responsibility e Accountability © Reimbursements General Guidelines for Proper Charting 1. Charting should be consistent with your employers written policies “If you did it or saw it, you should chart it, if you didn’t chart it, you didn’t do at? Charting should include any interactions with staff members or doctors, including failed attempts to reach them, concerning the care of a patient 4. Do not erase an error or remove pages, draw a line thru the error, note, it was mistaken entry and initial it Records should be clear, legible, accurate and should use proper terminology 6. Chart chronologically at the time of occurrence or as soon as possible afterward 7. Charting should be in ink and signed appropriately ioe) mn F-DAR Charting (Focus) It is a method of charting nurses use, along with the other disciplines, to help focus on a specific patient problem, concern or event. It is geared to save time and decrease duplicate charting. Purpose e Brings the focus of care back to the patient and the patients’ concerns. Instead of a problem list or list of nursing and medical diagnosis, a focus column is used that incorporates many aspects of patient care. The focus might be patient strength, problem, or need. Topics that may appear in the focus column include patients’ concerns and behaviors; therapies and responses; 239 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care changes in condition; significant events such as teaching, consultation, monitoring, management of activities of daily living or assessment of functional health patterns. The narrative portion of focus charting includes Data, Action and Response(D A R). The principal advantage of focus charting is in the holistic emphasis on the patient and his/her priorities including ease in charting. Objectives e To easily identify critical patient issues/concers in the progress notes. e To facilitate communication among all disciplines. e To improve time efficiency with documentation. e To provide concise entries that would not duplicate patient information already provided on flowsheet/checklist. General Guidelines e e e e Focus charting must be evident at least once every shift. Must be patient-oriented not nursing task-oriented. Indicate the date and time of entry on the first column. Separate the topic words from the body of notes: o Focus note written on the second column. o Data, Action and Response on the third column. Sign name (e.g. M. Aquino, RN) for every time entry. Document only patient’s concern and/or plan of care, e.g., health teaching per shift, hence, general notes are not allowed. Document patient’s status on admission, for every transfer to/from another unit or discharge. Follow the do’s of documentation. For eight hours shift, use blue or black ink for morning and afternoon shift, red ink for night shift. Specific Guidelines Begin with comprehensive assessment of the patient using inspection, Date Include in the assessment collection of information from: the patient; family; existing health records (such as checklist/flow sheets, laboratory results); and other health care providers. Establish a focus of care, to be addressed in the Progress Notes. Document the four elements of focus charting, as necessary, wherein: o Focus identifies the content or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication. o Data is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event. 240 Hospital Nursing Service Administration Manual

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Nursing Information Management System Action describes the nursing interventions (independent, basic and perspective) past, present or future. Response describes the patient outcome/response to interventions or describes how the care plan goals have been attained. Date/Time/Shift Focus D-Data, A-Action, R- Response 06/17/2019/6am-2pm/ | Nausea related to | D-Patient states she’s Jam anesthetic effect nauseated, Vomited 100ml clear fluid iv 7:05am A-Emotional reassurance given, vital signs taken and recorded Ziv 7:10am Referred to Dr. Ramos with ordered Compazine 1mg IV 7:15am STAT given ziv 7:45am Nausea related _to | R- Patient stated, no further anesthetic effect vomiting and nausea___ziv Zenaida I. Villaluna, RN Focus note is necessary: co To describe a patient’s problem/focus/concern from the care plan - when the purpose of the note is to evaluate progress toward the defined patient outcome from the plan of care. Examples: — Self care Skin integrity Activity tolerance To identify an exception to the expected outcome — when the significant finding or an outcome is not expected (the exception). Examples: | Wheezes left base Nausea To document a new finding — when the purpose of the note is to document a new sign or symptom or a new behavior which is the current focus of care. (These may be “temporary foci” which do not need to be incorporated on the plan of care because they can quickly be resolved. Even if you are uncertain as to whether the sign or symptom is important, it is valuable to communicate the information to the health care team.) To document an acute change in patient’s condition — when there has been an event of new patient condition. Examples: Respiratory distress Seizure Code blue To document a significant event or unusual episode in patient care — when: 24] Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care (a) responsibility for patient care changes from one department to another (b) a significant treatment/ intervention took place. Examples: — Admission: Pre - (specify procedure) assessment Post — (specify procedure) assessment Pre -transfer assessment Discharge planning Discharge status Transfusion RBC Start thrombolytic therapy PRN medication required o To document an activity or treatment that was not carried out — when treatment or activity in the flow sheet was not provided to the patient or was different from the standard of care. © To describe all specific patient/family teaching — this is in compliance with a standard of care. o To identify the discipline making the entry as well as the topic of the note — when all members of the patient care team use one patient’s program record. Examples: Social service/financial assistance Dietitian/instruct low fat diet Physical therapy/crutch walking o To best describe patient’s condition in relation to medical diagnosis — when the patient’s focus is the pathophysiology rather than patient’s response to the problem. This happens most frequently in highly technical areas such as critical care. e Data statements contain objective and/or subjective information. e Action statement contains only nursing interventions (basic, perspective, independent) past, present or future. e Patient outcome are evident in the response statements. e Data, Action, Response only contain information related to the focus, none of the information is extraneous (e.g., asleep, watching TV, visited by family). e Response statements are documented after PRN medications are administered. e Information from all those categories (Data, Action, and Response) should be used only as they are relevant or available. However, all appropriate information should be included to ensure complete documentation. 242 Hospital Nursing Service Administration Manual

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Nursing Information Management System Documentation - DO’s and DON’T’S DO’s DON’T’s e Do read what other providers have written before providing care and before charting. e DO time and date all entries. e DO use flow sheet/checklist. Keep information on flow sheet/checklist current. DO chart as you make observations. e DO describe patients’ behavior. DO use direct patient quotes when appropriate. e DO be factual and complete. Record exactly what happens to patient and care given. e DO draw a single line through an error. Mark this entry as “Mistaken “and sign your name. e DO use next available line to chart e DO document patient’s current status and response to medical care and treatments. | « DO write legibly. DO use standard chart forms. e DO use only approved abbreviations. DON’T begin charting until you check the name and identifying number on the patient’s chart on each page. DON’T chart procedures or chart in advance. DON’T clutter notes with repetitive or frequently changing data already charted on the flow sheet/checklist. DON’T label a patient or show bias. DON’T try to cover up a mistake or accident by inaccuracy or omission. DON’T “white out” or erase an error. DON’T throw away notes with an error on them. DON’T squeeze in a missed entry or “leave space” for someone else who forgot to chart. DON’T write in the margin. DON’T use meaningless words and phrases, such as “good day” or “no complaints.” DON’T use notebook, paper or pencil. Nursing Kardex A Kardex is a medical information system used by nursing staff as a way to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change. Objectives To provide information on: e Personal data. Physician’s orders. Medications. Treatment. Procedures. Intravenous therapy. Laboratory and other diagnostic. Allergies. Diet Hospital Nursing Service Administration Manual 243

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The Management in the Delivery of Nursing Care Policy e The patients Kardex originates in the unit to which the patient is admitted. e Upon admission the nurse writes all the information of the patient on the kardex. o Personal date. Physician’s order Laboratories, radiologic studies. Medications. Special procedures and information e Kardex should be used as means of communication between shifts and nurses and used at handover of shift. e Kardex is updated with each change of orders. oo0°0 Discharge of Patient e All patients to be discharged must have a written physician’s order. e Release patients with a written discharge clearance / slip duly signed by the nurse. e Indicate the accurate date, time patient is discharged, mode, condition and companion at the nurses’ notes. e Date and time of discharge should coincide with that of the clinical face sheet. Discharge Against Medical Advice (DAMA). (Please refer to Manual of Standards and Guidelines on the Management of the Hospital Emergency Department). e There must be a written physician’s order e Accomplish appropriate form e Follow all procedures on discharge patients. Death e Record date and time patient was pronounced dead by the physician (specify name); postmortem care rendered and time the patient was transferred to the morgue. e Sign entries legibly. 244 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership 14 ETHICO-LEGAL IN NURSING LEADERSHIP Introduction The role of the professional nurse has expanded rapidly within the past decades as we enter the millennial era, to include increased expertise, specialization, certifications, autonomy, accountability and independent practice. This has forced nurse managers to increase awareness of the interaction of legal and ethical principles. This protects the nurse as she performs her task and her patient who expects that she gets the care she deserves. Nursing practice is affected by ethical and legal considerations. Laws are formal rules of conduct which the members comply with and recognize as enforceable by a controlling body. Ethics are set of principles or values that govern the individuals’ action in a society. Nurses are bound by their personal values and the rules governing their professional conduct. For nursing administrators, it is important to determine what they value most so as to help their nurses determine their own. It is important that personal ethics do not go against their professional ethics. The Philippine Nurses Association (PNA) has set the guidelines on ethical practice of nurses when it promulgated the Code of Ethics for Registered Nurses in its Board Resolution #220, Series of 2004. It described the ethical principles that govern the relationship of the registered nurse and people, their practice, co-workers, society and environment, as well as to her profession. Ethical Concerns Confronting Nurses 1. The confidentiality of records 2. The patient’s right to privacy 3. The patient’s right to information regarding medical procedures and their implications 4. The patient’s competent consent to treatment 5. The patient’s right to refuse treatment 6. The quality of service provided to severely disabled elderly or terminally-ill patients 7. Termination of treatment In addition to recognizing issues, the nursing manager must make decisions that involve ethical concerns. These decisions can be made and ethical issues can be 245 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care resolved to some extent through collaboration with institutional resources, such as ethics committees and the use of a decision-making process that carefully identifies an ethical component in analyzing and arriving at a decision. Ethical Principles

1. Autonomy. Addresses personal freedom and the right to choose to a course of action free of correction. Informed consent is a direct example of this principle. This also shows that the nurse’ clinical practice is reflected in her own decision making Basis for progressive discipline as the employee has the option to meet the expectations or take full accountability of her action.
2. Beneficence. This states that the action one takes should promote good outcome. For nurse managers, this encourages the employees’ positive attributes and qualities and guide positive direction for growth.
3. Non-Maleficence. It involves an ethical and legal duty to avoid harming others. It is based in the Latin maxim, “Primum Non-Nocere or First Do No harm”. This principle involves area of healthcare practice including treatment procedures and the rights of patients.

Veracity. Truth should be told. As nurse managers, they have to tell all the facts of a situation truthfully and assist the nurse to make decisions. 5. Justice. Equal and fair treatment to everyone. This is the principle that dictates that there should be no favoritism by nurse managers. All nurses under her must be treated equally and given all the chance for continuous training. 6. Paternalism. Allows one to make decisions for another. This principle allows assistance for their staff to make decision when they do not have sufficient data or expertise. Nurse Managers can use this principle and laying out a career path for their nurses. 7. Fidelity. Keeping one’s promises or commitments. Nurse Managers abide by this principle when fulfilling their promises to their employees such as promised promotion, etc. 8. Respect for others. This principle acknowledges the right of individuals to make decisions and live them. These include sender issues, cultural differences, religion, etc. Nurses and their managers make decisions daily in their workplace. There are various models for this. Here is one model that may be adopted or used as a guide in decisions. 246 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership WV. IMPLEMENT AND EVALUATE L CLARIFYING THE PROBLEH 13. Make an action plan

1. Identify the uncertainty
2. How do you and others feel?
3. Analyze your Biases
4. What have | learned?
5. Clarify the Question
6. Moral Distress or Residue?
7. List major stakeholders Ethical Theories* Utilitarianism —- Consequentialisrn Deontology _Relational Ethics Virtual Ethics : Principles Values \ Autonomy. Organizational Beneficence Personal Nan-tnaleficence Professional Justice Cornrnunity IIL CHOOSE A SOLUTION : IL DESCRIBE THE ETHICAL CONSIDERATIONS
8. List Options . .
9. Clinical Issues
10. Consider all Relationships
11. Contest
12. Make a choice and justify it.
13. Risks and Consequences
14. Applicable Rules and Duties
15. Ethical Principles Figure 14,1Ethical Decision Making Framework (adapted from: Ethics Services, Winnipeg Regional Health Authority 2015) The model states that there are four aspects in ethical decision-making such as: Clarifying the problem Describing the ethical considerations Choosing a solution Implementing and evaluating the choice through development of action plan ae te BS Under each aspect are steps that will guide the nurse to follow in order to arrive at a decision objectively. The end output will be a plan of action for implementation. Guidelines for Ethical Decision-Making

Know your values. Take some time to determine what you value high enough to defend. 2. Do not allow your values to be compromised. Giving in to a situation may temporarily solve the problem but in the long run, this may build disrespect for yourself, the hospital/agency or the person who asked you to compromise. 3. Be familiar with the Code of Ethics for Nurses. Acting within ethical bounds- is what makes you a professional nurse. 4. Do not allow your nursing ethics to be compromised. Allowing your personal ethics to be violated leads to disrespect and violation of your professional ethical standards and adversely affecting professional reputation. 247 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 5. Do not force your personal values on others. What works for you may not work for others. 6. Do not be disappointed when some people fail to meet your expectations. Values differ among people. 7. Remember that the client’s well-being and safety is your ethical responsibility. Ethical Conflicts Ethical dilemmas occur when a solution to a conflict encroaches on the interests and welfare of another. J. Autonomy versus Paternalism Freedom of choice requires that full information be given to the patient; thus, informed consent is defined as the right of competent adults to accept or refuse medical treatment on the basis of full information. Paternalism, on the other hand, claims that beneficence (doing good for others, being helpful) should take precedence over autonomy. Example: If a patient needs a technological therapy that the physicians view as lifesaving but the patient views as unnatural and unbearable, he or she may make an informed decision that the benefit does not outweigh the psychological and physical costs. The patient may then refuse the therapy. 2, Justice versus Utilitarianism Justice demands that people have an opportunity to obtain the health care they need on an equitable basis. Utilitarianism states that the morally right thing to do is that act that produces the greatest good (for the greatest number of people, or society). 3. Veracity versus Fidelity The concept of veracity refers to truth - telling, honesty, or integrity. The nurse, as a professional, has an obligation to tell the truth. Fidelity is related to trust, or to the promises we make. Professional nurses promise to care for a patient to the best of their ability. As the nurse carries out this trust relationship and strives to deliver safe, quality care to the patient, conflicts may arise with other responsibilities the nurse has, e.g., to perform a painful or potentially dangerous procedure). Veracity conflicts with fidelity in these situations. Telling the patient truthful information that could cause the patient distress may conflict with protection of that patient. 4. Professional Integrity vs. Remaining True to One’s Own Ethical and Moral Beliefs Conflicts between professional integrity and remaining true to one’s own ethical and moral beliefs occur in various situations. Such conflicts might 248 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership result in objecting to delivering certain types of treatment or to caring for certain types of patients. Technological Concepts and Ethical Practice The use of technology yields benefits including enhanced communication and symptom management. Ethical concers arise regarding willingness or ability to use technology, disconnection from human aspects of care, and potential for inequitable availability. The use of technology for good (beneficence) is evident in multiple studies showing outcomes ranging from better self-management of illness to improved patient satisfaction in terms of access to healthcare. Rural residents, in particular, report improved healthcare access, as transportation issues are minimized or eliminated. Threats to human good include potential consequences if information received is misunderstood, increased dependence on technology, and lack of consistent evidence demonstrating the effectiveness of ICT in health promotion (Korhonen et al., 2015). The possibility for harm raises the ethical principle of non-maleficence. Harm might occur as a result of actions undertaken without understanding presented information, if the technology fails, or if privacy and confidentiality are breached. Threats to autonomy arise when users do not understand or give their informed consent. Justice is threatened when similar technology is not available for everyone, and when the patient has limited ability to use it (Korhonen et al., 2015). It is clear that the ethical principles of beneficence, non-maleficence, autonomy and justice pertain to the use of technology in caring science. An examination of the literature specifically relating to the use of health technology follows. Ethical Considerations in Patient Care Responsibilities All nurses are expected to recognize their responsibilities toward their patients. Nurses have a responsibility to recognize when the care and safety of a patient is in jeopardy. This recognition is grounded in the application of sound concepts of patient care, taking into account differing but valid practice techniques. e Nurses have a duty, as moral agents, to intervene to prevent harm to patients. e Nurses should seek the least harmful and least disruptive methods of ensuring patient protection. e Nurses who are employed in institutions or groups have a responsibility to make every effort to utilize and exhaust the internal reporting mechanisms before notifying public agencies or the general public; such notification is generally referred to as “whistleblowing”. e Nurses should seek to minimize harm to colleagues and the institution as well as patients. In crisis or emergencies, a nurse’s first and overriding responsibility is to patients. 249 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Nursing Administrator / Manager Actions e Promote a climate in which employees are encouraged to report those situations which may adversely affect the delivery of quality care. e Identify those persons or those practices which may cause actual or potential harm to the patient. e Establish mechanisms for reporting and handling instances of incompetent, unethical, or illegal practice. e Maintain confidentiality in appropriate circumstances. e Respond to those situations which involve unacceptable practices by determining through investigation that a problem exists, including verification and documentation of facts. e Respond further to unacceptable practices by taking actions to halt the harmful practice, such as the following:

Reporting facts in accordance with established institutional processes

Ensuring that practitioner(s) receive appropriate notification and referral if a pattern of unsafe practice occurs

Ensuring appropriate notification and counseling to the injured party if there has been actual or potential injury to the patient

Adhering to institutional disciplinary policies and procedures when just and appropriate e Participate in the development of specific procedures for identifying and reporting incompetent, illegal or unethical practice. Staff Nurse Action e Identify and confront those individuals on the health care team whose clinical practice clearly presents a danger to the health or safety of the client under their direct or indirect care. e Report to the appropriate authority the individual whose unethical or unsafe practice has been confronted without an acceptable solution. e Recognize the necessity of further reporting if the problem is not resolved at the initial reporting level. © Participate in the development of specific procedures for identifying and reporting incompetent, illegal, or unethical practice. Nurse’s Legal Responsibility for Patient Care (Philippine Nursing Act of 2002 R.A. 9173) Legally, nurses are required to perform their duties according to accepted standards and within the scope of practice as contained in the Philippine Nursing Law. Such duties should always be directed toward achieving the optimal well-being of the patients/clients. Such care must be at a level that is reasonable under given circumstances. It should reflect the nurse understanding of the nursing law, and use of nursing standards, policies, procedure manuals, job descriptions and the Patient’s Bill of Rights. 250 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership Common Liabilities that Nurses May Incur Negligence is the omission (not doing) or the commission (doing) of an act that a reasonably prudent person would or should not do under normal circumstances. Specific examples of professional negligence are: e Failure to exercise reasonable judgment in the performance of duty. e Failure to properly administer drugs, treatments, medications and failure to report its adverse reactions. e Failure to verify a subordinate’s competence prior to the assignment of duty. e Failure to document and endorse significant assessment findings resulting to omission of prudent clinical medical and nursing interventions. e Failure to provide safety measures resulting in the injury of patients. Inability to forecast possible harm to patients, such as, suicidal or psychiatric cases or from unforeseen events. Improper handling of equipment. Loss of, or damage to, patient’s property. Failure to follow the standard in the performance of surgical counts. Failure to take action or make a report when required to do so. Leaving the patient/unit without a reliever, proper endorsement, and approval of authorized superior. Elements of Negligence Duty. The defendant owed a legal duty to the plaintiff under the circumstances. Breach. The defendant breached that the legal duty by acting or failing to act in a certain way. Causation. It was the defendant's action or in action that actually caused the plaintiffs injury. Damages. The plaintiff was harmed or injured as a result of the defendant’s actions. Incompetence. Refers to a person’s inability to perform a required duty. Although a nurse is registered, if he/she manifests incompetence in the performance of her duty, her certificate of registration may be revoked or suspended. Malpractice. Refers to the negligent act committed in the course of performing one’s duties. For nurses, malpractice may come in the form of giving the patient improper or unskilled care or performing acts which are outside the scope of their functions. The nursing service must review standards periodically to ensure that these remain current and attained to the new technology and current ways of performing tasks. Nurses must also be sent to certification of competence trainings to equip them with the skills necessary in their practice. Res Ipsa Loquitur. The term literally means “the thing speaks for itself’. Three conditions are required to establish negligence under the doctrine: 251 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care The injury would not have occurred normally unless someone was negligent. The injury was caused by something within the exclusive control of the defendant. 3. The injured party did not contribute in any way to his own injury. Ne Examples would include: sponges left inside the patient’s body, burns resulting from hot water bags and fracture or injuries sustained by the elderly, confused, unconscious or sedated patients. Respondent Superior. This term means “let the master answer for the acts of the subordinate”. It is not a shift of responsibility from the employee to the master. The employee still remains fully responsible for the act. Example: Nursing students take care of patients within their level of preparation. If the nursing student performs a task she is not yet capable of doing, the designated clinical instructor or the nurse in charge of the unit where the student is working, can be held liable. Nursing students should not be given tasks which they could not handle yet to avoid risks or injury. e Liability of Supervising Nurses. Supervising Nurses should likewise utilize competence with corresponding authority as the basis for delegating responsibilities to subordinates. New and inexperienced employees should therefore be under close supervision. The supervision will be measured against the standard of what a competent and prudent Supervising Nurse does in the performance of his/her duties. e Liability of Nursing Attendants. Nursing attendants perform selected nursing activities under the direct supervision of the nurses. Their responsibilities usually pertain to routine long term care of patients. They are usually given on-the-job training by the nursing staff. After this training, they are liable for their own actions. If a nurse delegates her function to the nursing attendant and the latter commits a mistake, the former will be held liable for the mistake. e The Nurse’s Responsibility for the Patient’s Safety. Nurses are responsible for providing safe care both physically and psychologically. Equipment, such as, stretchers, wheelchairs and beds should likewise promote an environment conducive to recovery. Restraints like confining a person in bed can be misinterpreted as a form of punishment, therefore, it cannot be instituted _without_a doctor’s order. However, in case where a patient is in danger of hurting himself and others, the nurse can apply the necessary restraint provided that an accurate documentation is made. 252 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership e Emergency Care. When a patient is brought to the Emergency Room (ER) for treatment, it is implied that he/she is consenting to the measures the physician deems necessary for his/her condition. Nurses should observe and properly record the patient’s condition and the treatment he/she received. In many cases, patients brought to the ER are medico-legal cases and the nurses must be conscious of its legal implications to them and the hospital. A written consent should be obtained from the patient or in cases of children, from their parents. It is to be noted, however, that in emergency cases, treatment may be instituted as a means to save life. The doctor attests to this and the patient signs it. This is called therapeutic privilege on the part of the doctor. e Consent (Right to Informed Consent).Patients have the right to choose whether they desire medical care or not. A consent signed by the patient should be obtained before beginning any treatment or care. The patient must be aware of the treatment that would be given to him/her, the possible complications, danger and risks that may take place and other alternatives to the proposed therapy or treatment which maybe considered. The patient has the right to consent or refuse such treatment. The general consent taken upon admission is for initial treatment. Special procedures, such as, surgery, biopsy, spinal puncture, blood transfusion and X- ray procedures necessitating the administration of dyes would require another consent. A patient who consents must have the legal capacity to do so, meaning he is of legal age, and knows what he is consenting to. Patients who are sedated. distraught, or who cannot comprehend cannot give an informed consent. No consent is necessary for emergency cases where a patient’s life is at stake. However, this should be properly witnessed and the doctor should make the necessary notation on the chart. When a patient refuses to give his/her consent, verify his/her reason, he may just need further explanation. However, should the patient still refuse, he cannot be forced to sign the consent. This reaction should be properly noted on the patient’s chart through a waiver. Therapeutic Orders Therapeutic orders should be legal, written, clear, timed and signed by the ordering physician. Signing an order is the legal proof that such an order has been made. If the order is unclear, verify from the ordering physician. Do not risk the patient’s life with an incorrect or an unclear order. Medicine administration is a high risk area because errors may be fatal. Nurses should be familiar and kept updated with drug preparation, dosage, action, route, frequency, side effects and adverse reactions. 253 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Since the quality of care given to patients is reflected in their charts, it is imperative that the nurses’ notes be clear, accurate and up-to date. What is not charted has not been observed, nor administered nor done. There are occasions when nurses give telephone reports to physicians about changes in the patients’ conditions. Information given through telephone should be accurately transcribed by the receiving nurse in written form especially if this pertains to medications, or if significant events or changes in client’s condition have occurred. There are legal risks in telephone orders. These may be understood or misinterpreted by the receiving nurse. They may sound unclear because of some trouble in the telephone line. Most importantly, if the signature of the ordering physician was not present and this order may be denied in case errors exist or when court litigations arise. Only in an extreme emergency and when no other physician is available should a nurse receive telephone orders. The nurse should read back such order to the physicians to make sure the order has been correctly received. The nurse should note the date and time when the order was made, the name of the physician making the order, then sign his/her own name including designation. The ordering physician should sign the order as soon as he arrives in the unit. Clear hospital policies with regards to receiving telephone orders should be established to avoid misunderstanding and legal risks. Causes of Malpractice for Nurse Managers and Nurses

1. Delegation and Supervision. The nurse manager should delegate tasks appropriately. She has the duty to ensure that the staff members under her supervision are competent. She should be aware of the staff's knowledge, skills and attitude and that they maintain their competence. Knowingly allowing a staff to function below the standard of care subjects both the nurse managers and the institution for potential liability. Some means of ensuring continued competence are continuing education and certification programs assigning the staff to work with a mentor or coach to improve technical skills. e Liability of Nursing Attendants. Nursing attendants perform selected nursing activities under the direct supervision of nurses. These activities usually pertain to the routine long-term care of patients. They undergo on-the-job training by the nursing staff. After these trainings, they are liable for their own actions. If the nurse delegates her functions to the nursing attendant and later commits mistakes, the former will be held liable for the mistake. e = Liability of Supervising Nurse. Supervising Nurses should likewise utilize competence with corresponding authority as the basis for delegating responsibilities to subordinates. New and inexperienced employees should therefore be under close supervision. The supervision will be measured against the standard of what a competent 254 Hospital Nursing Service Administration Manual

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Ethico-Legal in Nursing Leadership and prudent Supervising Nurse does in the performance of his/her duties. 2. Staffing Issues. There are some issues that arise with staffing. These include adequate number of staffs in a time and advancing acuity and limited resources, floating or pulling out staff from one unit to another. Guidelines for nurse managers in short staffing issues include alerting the top management and upper level managers of concerns. The nursing service must notify the chief of the hospital about the staffs’ problems. There are some measures that can be taken to address these concerns and can be recommended such as: closing certain units, restricting elective surgeries, hiring new staff, approval of overtime for adequate coverage, restricting admissions in new areas. 3. A Consent should be obtained before beginning any treatment or care. The patient must be aware of any possible complications, danger, and risks that may occur. The patient has the right to consent or refuse such treatment. The several consents taken upon admission is for initial treatment. Special procedures such as biopsy, bloody transfusion, surgery etc. will necessitate another consent. The patient must have the legal capacity to do so, of legal age and knowing what he is consenting to patients who are sedated, distraught, or cannot comprehend, cannot give an informed consent. No consent is necessary for emergency cases where a patient’s life is at stake. This should be properly witnessed and the doctor should make the necessary notation in the chart. If the patient refuses to give consent, the doctor properly takes note of this on the patient’s charts through a waiver. 4. Emergency Care. \t is implied that the patient is consenting to measures which the doctor deems necessary when a patient is brought to the ER. The nurse should observe and properly record the patients’ conditions and the treatment she receives. It is noted that in emergency cases, treatment may be instituted as a means to save a life. The doctor attests to this if the patient signed it. It is called therapeutic privilege on the part of the doctor. 5. Therapeutic Orders Should be legal, written, clear, timed, and signed by ordering physician. If the order is unclear, verify from the ordering physician. Medicine administration is very risky because errors may be fatal. Nurses should be familiar and kept updated with drug preparation, dosage, action, route, side effects, and adverse reaction. Quality of care given to patients is reflected in their charts. It is imperative that the nurses’ notes be clear, accurate, and up- to- date. What is not documented is not observed, administered, or done. There are times when a nurse may receive telephone orders, but this is only on extreme emergency. The nurse should read back the order to physicians to make sure the order has been correctly received. The nurse’s notes, the date and time the order was made and the name of the physician making the order, then sign her name including designation. The ordering physician should sign the order as soon as he can. Clear hospital policies with regards to receiving telephone orders should be established to avoid any legal risk. 255 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Disciplinary Action on Errors The disciplinary action will follow rules provided for by the Civil Service. This will be handled by and at the direction of the Nursing Administrator on his designee. The judgment resulting in the disciplinary action will be based on the severity of the error, the action and the reaction of the nurse involved, the number of errors in an annual period. The nursing administration reserves the right to institute immediate discipline, including termination for an error that has caused damage to a patient. The right to institute immediate discipline also applies to any nurse who demonstrates negligence or gross neglect in her action. The process is based on the Civil Service rule on discipline. To avoid legal problem, the nurse must be aware and conscious of observing the rights of the patients at all times: Right to good health Right to information and confidentiality Right to privacy e.g. visual and auditory Right to withdraw consent without prejudice to care Right to second opinion fT > I Ol ES Informed consent includes the patient-doctor discussions of the following issues: the nature of the decision or procedure, reasonable alternatives to the proposed intervention, relative risks. benefits, and uncertainties related to alternatives. assessment of patient's understanding and patient’s acceptance or refusal of the intervention (source: PHIC- Hospital Handbook — 2" Edition) To maximize the quality of care that are nurses learning into the care of their clients, it is necessary to protect the dignity and the autonomy of nurses in the workplace. The following are recommended to be upheld:

1. Nurses have the right to practice in a manner that fulfills obligations to society and to those who receive nursing care.
2. The right to practice in environments that allow them to act in accordance with professional standards and authorized scopes of practice.
3. The right to a work environment that supports and facilitates ethical practice in accordance to the Code of Ethics.
4. The right to freely and openly advocate for themselves and their patients without fear of retribution.
5. The right to fair compensation for work consistent with their knowledge, experience, and professional responsibilities.
6. The right to a work environment that is safe for themselves and their patients.
7. The right to negotiate the conditions of their employment either as individuals or collectively in all practice settings. 256 Hospital Nursing Service Administration Manual

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Human Resources Management 1 5 HUMAN RESOURCE MANAGEMENT Introduction Globally, health systems are experiencing major shifts in their structure, organization, functions and management. Globalization and the modernization of health sectors are creating an increasingly diverse yet interconnected world. Within this ever-changing milieu, nurse managers are faced with many challenges, each demanding effective and dynamic leadership and management abilities if they are to be addressed adequately. The effective management of human resources (HR) will therefore continue to play a key role in the achievement of health outcomes, as well as being an important part of ensuring that the most effective use is made of scarce human and financial resources. The development of a competencies framework aims to assist nurses in preparing for this key role. Human Resource Management It is the organizational function that deals with issues related to people such as compensation hiring, performance management, organization development, safety, wellness, benefit, employee motivation, communication and training. Employing people, developing their resources, utilizing maintaining and compensating their services in tune with the job and organizational requirements. Importance of Human Resource Management Attract and retain talents Train people for challenging roles Develop skills and competencies Promote team spirit Develop loyalty and commitment Increase productivity and profits Improve job satisfaction Enhance standard of living Generate employment opportunity Greater task and respect Dd Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Steps of Human Resource Management Recruitment Selection Placement Deployment Promotion Recruitment and Selection Process

"01 ducts 3: Preparation of appointment Figure 15.1 Recruitment and Selection Process

1. Recruitment is a process of searching and obtaining applicants for job, from among whom the right people can be selected. Types of Recruitment e Planned — arise from changes in an organization and recruitment policy e Anticipated — by studying trends in the internal and external organization e Unexpected — arise due to accidents, transfer, illness Sources of Recruitment e Internal Source — transfer

Promotions

Upgrading

Demotion 258 Hospital Nursing Service Administration Manual

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Human Resources Management e External — press advertisements

Placement agencies

Notice boards Modern Sources of Recruitment e Walk-in e Consult-in e Tele-recruitment — organization advertises the job vacancies through World Wide Web (www) Steps in Recruitment 1. Planning 2. Strategy Development 3. Searching 4. Screening 5. Evaluation and Control Purposes and Importance e Determine the present and future requirement of the organization in conjunction with the personal planning and job analysis activities. e Increase the pool of job candidates with minimum cost. e Helps increase the success rate of the selection process, reducing the number of obviously under-qualified or over-qualified. e Helps reduce probability that job applicants that once recruited and selected will leave the organization only after a short period of time. e Start identifying and preparing potential job applicants who will be appropriate candidate. e Evaluate effectiveness of various recruiting techniques and sources for all types of job applicants. Principles of Recruitment e Recruitment shall be done from a central place (Example: Nursing Service) e Only vacant position should be filled or neither less nor more should be employed e Job description/work analysis should be made before recruitment e Recruitment should be done on the basis of definite qualification and standard e Policy should be clear and changeable to the need 259 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 2. Selection is the process of choosing from among applicants, the best qualified applicants The selection process starts when applicants are screened in the Personnel Department. Selecting includes interviewing the employer’s offer, acceptance by applicant, and signing of a contract or written offer. e Interview — verbal interaction between individual for a particular purpose Types of Interview e Formal Informal Structured Depth Group Panel Steps of Interview 1. Preparation on the interview 2. Conducting the interview 3. Closing of the interview 4. Evaluation of the interview Those applicants whom seem to meet the job requirements are sent blank - job application forms and are directed to fill it up and return the same for further action. The job application form is one of the most important tools in the selection process. Advantages of Promotion Policies e It provides incentives to employee to work more and show interest in their work. They put in their best and aim for promotion within the organization. e Develops loyalty amongst employee e Increases satisfaction amongst employee e Increases effectiveness of an organization Solution to Promotion Problems e Inpromoting an employee to a better job, his salary should be at least one- step above his present salary e Specific job specification will enable an employee to realize his qualifications are equal to others e There should be a well-defined plan for informing prospective employees may know the various avenues for the promotions The promotion policy should be made known to its every and organization e Management should prepare and practice sincerely 260 Hospital Nursing Service Administration Manual

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Human Resources Management 3. Placement is a process of assigning a specific job to a selected candidate or assignment of specific task and responsibility 4. Deployment process of using personnel in an effective and efficient way 5. Retention— possession of employees by the employer e How to retain Communicate vision Show value Share passion Be honest Promise learning Take questions 6. Promotion is there-assignment of individual to a job of higher rank or advancement involving change and job that is better in terms of status and responsibility

Advancement of an employee from one position to another with an increase in duties and responsibilities and usually associate with increase in salary Types of Promotion e UP or OUT - either earn a promotion or seek employment e Dry Promotion — compensation is adjusted keep pace with cost of living Types of Pension e Employment-based Pension © Social-state Pension e Disability Pension Human Resource Development (HRD) Program The quality of service rendered by the nursing personnel depends on their knowledge, skills and attitudes. Development in science and technology, socio-cultural changes, changing patterns on morbidity, mortality turnover rate of nursing personnel, increase in nursing personnel, and the expansion of their roles and functions necessitates a truly effective human resource development program. The Chief Nurse is responsible for the quality of service rendered by nursing personnel, to ensure that staff accountabilities and responsibilities are consistent with their qualifications, trainings, experience, education, registration and licensure. She is responsible for the planning, implementation and evaluation of the development program. She should require membership to all accredited nursing professional associations for continued growth and development. She is responsible for developing comprehensive program of staff training to meet organizational goals and educational 261 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care needs of staff and evaluating the effectiveness of these training and development programs. Scope of Human Resource Development e Learning and Development Intervention (LDJ). Plan that aligns to the CSC’s goals and aspiration becomes strategic and highly important. It provides a strategic alignment between the CSC workforce’s individual learning and development goals with the goals of the organization. e Training Needs Assessment. The needs of the organization or that of the personnel is assessed to determine what type of program is to be offered. Needs can be determined by interviews, observations, survey questionnaire to personnel or as planned by the agency itself. Needs become the basis for program planning and development. e Program, Development and Evaluation. Consider the benefits, the type of program accomplished, the behavior attained and the expected economic cost/benefit the HRD training will bring. e Training and Development involves acquiring knowledge, developing competencies and skills, and adopting behaviors that will improve performance in current jobs, including instructional systems design, train-the— trainer programs, and instructional strategies and methods. e Organization Development involves the diagnosis and design of systems to assist an organization with planning change. Organizational Development activities include: change management, team building, learning organizations, management development, quality of work life, management by objectives, strategic planning, participative management, organizational restructuring, job redesigning, job enrichment, centralization vs. decentralization, changes in the organization’s reward structure, process, consultation, executive development, action research and third party interventions. e Career Development involves activities and processes for mutual career planning and management between employees and organizations. Changes in the organizations are resulting in more empowerment for employees. The responsibility for one’s own career development is downloaded to him/her. e Organization Research and Program Evaluation, an exploration of methods to evaluate, justify and improve on HRD offerings. e The HRD Professions and Professional Organization. Plan to list and briefly describe the principal HRD organizations, their missions and goals, and their addresses and contacts. 262 Hospital Nursing Service Administration Manual

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Human Resources Management HRD can give the tools needed to manage and operate the organization. If people are sufficiently motivated, trained, informed, managed, utilized and empowered. Training and Staff Development Programs Staff development activities consist of the training and education provided by an employer to improve employee’s occupational knowledge, skills and attitudes. Managers at all levels of an organizations hierarchy are responsible for upgrading subordinates. Staff development activities are needed, because societal change and scientific advancement cause rapid obsolescence of nursing knowledge and skills. Benefits of Training and Development e Improved employee performance. The employee who receives the necessary training is more able to perform in their job. The training will give the employee a greater understanding of their responsibilities within their role, and in turn build their confidence. e Improved employee satisfaction and morale. The investment in training that a company makes shows employees that they are valued. Employees who feel appreciated and challenged through training opportunities may feel more satisfaction toward their jobs. e Addressing weaknesses. Most employees will have some weaknesses in their workplace skills. A training program allows you to strengthen those skills that each employee needs to improve. A development program brings all employees to a higher level so they all have similar skills and knowledge. e Consistency. A robust training and development program ensures that employees have a consistent experience and background knowledge. The consistency is particularly relevant for the company’s basic policies and procedures. e Increased productivity and adherence to quality standards. Increased efficiency in processes will ensure project success which in turn will improve the company turnover and potential market share. e Increased innovation in new strategies. Ongoing training and upskilling of the workforce can encourage creativity. New ideas can be formed as a direct result of training and development. e Reduced employee turnover. Staff are more likely to feel valued if they are invested in and therefore, less likely to change employers. e Enhances company reputation and profile. Having a strong and successful training strategy helps to develop your employer brand and make your company a prime consideration for graduates and mid-career changes. 263 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Orientation All newly employed personnel are entitled to be oriented to the hospital as a total institution and specifically to the Nursing Service. The orientation program usually includes a tour of the hospital setting as well as information on the vision, mission, philosophy, goals, objectives, structure of all hospital and the Department of Nursing. Functions of the various members of the nursing team and nursing care standards are usually emphasized. Components of the Orientation Program e DOH’s vision, mission, goals, organizational structure, program thrusts. e Hospital’s philosophy, goals, objectives, history, organizational set-up, functions of the different departments, the catchments area, ethics, Government Service Insurance System (GSIS), Personnel policies, physical tour. e Nursing Service Division’s philosophy, objectives, organizational structure, job descriptions, personnel policies, rotation of duties, leaves, etc. e Nursing unit’s physical layout, health team members, policies, job descriptions, records and reports, ward manuals, legal limitation of functions. Oftentimes the new employee is accompanied by a member of the Training Staff who serves as a preceptor for a few weeks after which the Senior Nurse takes over until she/he can handle his/her responsibilities independently and efficiently. Various types of in-service education programs are offered by the agency for the purpose of enhancing the worker’s performance effectively both as a person and as a professional nurse. These may be in the form of medications updates, demonstration of new equipment, research updates, and case presentations, skill training programs, values re-orientations, journal meetings, seminars, and conferences. Management or Supervisory Development Training is offered to nurses who have potentials for leadership positions or enhance the capabilities of those already on the job. This will give the agency a ready pool of trained nurses for supervisory positions. Skills training program for nursing specialties are offered by specialty hospitals such as Critical Care Nursing by Philippine Heart Center and St. Luke’s Medical Center, Pulmonary Nursing by the Lung Center of the Philippines, and Renal Nursing by the National Kidney and Transplant Institute. Evaluation of Human Resource Development Program Evaluation is a systematic and continuous process of ascertaining and appraising the effectiveness of an endeavor. The major focus of the staff of the HRD Program is to satisfy the educational needs of the nursing staff. Evaluation should deal with the skills, knowledge and attitudes of the learners. Information generated from the evaluation may be essential in planning future programs. 264 Hospital Nursing Service Administration Manual

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Human Resources Management Effectiveness Indicators on the HRD Program Learning objectives were achieved. Improved knowledge, attitudes and skills (KAS). A better quality of nursing care was achieved. Satisfaction on the part of personnel and clients served. Enhanced agency image. Factors considered in single program evaluation Relevance of program to the participant’s educational needs; Utilization of the principles of adult education; Qualified trainers; Goal-oriented course content; Measurable objectives; Appropriate learning experiences and methods of teaching; Adequate time for each learning activity; Appropriate facilities and resources; and Systematic recording system. Factors considered in the total evaluation of HRD Program (Short and long term goals) Administrative support Philosophy of the program consistent with that of the Nursing Service Goal-oriented policies and procedures Available resources Budgetary allocation for HRD Program Regular review of HRD Program Systematic recording Utilization of resources within and outside the agency Rule VII of the Omnibus Rules Implementing Book V of Executive Order No. 292 and other Pertinent Civil Service Laws provides the policies on career and personnel development in government: Every official and employee of the government is an asset or resource to be valued, developed and utilized in the delivery of basic services to the public. Every department or agency shall therefore establish a continuing program for career and personnel development for all agency personnel at all levels. Each department or agency shall prepare a career and personnel development plan which shall be integrated into a national plan by the Commission. 265 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Each department or agency should have a human resource development office created or a staff assigned solely for the purpose of attending to the agency’s human resource development function. e Every department or agency is mandated to ensure that each agency personnel shall have undergone at least on planned human resource development intervention during the year. e A specific budgetary allocation of at least 3% of the annual budget shall be set aside for human resource development. Such program shall include the following: o Induction Program refers to the program for the new entrants in government to develop pride, belonging and commitment to public service © Orientation Program refers to activities and courses and designed to inform new employees about agency government programs, thrusts and operations as well as on their duties and responsibilities as well as benefits o Re-orientation program refers to courses designed to introduce new duties and responsibilities, new policies and programs to employees who have been in the service for quite sometime © Professional/ttechnical/Scientific Programs are programs on specific professional/technical/scientific areas for enhancement of skills and knowledge of second level personnel in the career service o Employee Development Program refers to courses aimed at maintaining a high level of competence on basic workplace skills among employees in the first level career service. o Middle Management Development Program refers to asset or series of planned human resource interventions and training courses designed to provide division chiefs and other official of comparable ranks with management and administrative skills and to prepare them for greater responsibilities o Values Development Program are courses which are designed to enhance and harness the public service values of participants to be effective government workers o Pre-retirement Program refers to courses which are intended to familiarize would be retirees on the government retirement plans and benefits as well as available business opportunities or other or who options o Executive Development Program refers to activities and experiences and continuing education intended to enhance the managerial skills or government officials One program the CSC offers is the conduct of the following values related programs. They are intended to minimize graft and corruption in the government: a. Alay sa Bayan (ALAB) is intended for new entrants in the government; an initiation program which intends to develop loyalty, love of country, sense of pride, belongingness, and commitment to public service 266 Hospital Nursing Service Administration Manual

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Human Resources Management b. Values Orientation Workshop (VOW).This program is for employees who have established roots in the organization or who may have developed complacency due to long stay in the service c. CSC also trains prospective trainers from within and other government agencies to have a multiple effect. d. Trainers Training on Alab (TALAB) e. Trainers Training on Vow (TIVOW) Scholarships The government-wide Local Scholarship Program (LSP) aims government employees with education opportunities to enhance personal growth and development. In the past, LSP included grants for the completion of a master’s degree, the completion of a bachelor’s degree and grants for skilled workers in the government. Presently, only the LSP — Master’s Degree Courses is being offered. Study Leave Qualified employees, excluding those in the teaching profession, may apply for study leave not exceeding six months with pay for the purpose of helping them prepare for bar or board examination. For completion of master’s degree the study leave shall not exceed six months. Personnel Development Committee Mandated to be established in every department and agency which shall provide support functions to matter pertaining to selection of agency nominees to training, development and scholarship programs in accordance with existing civil service policies and standards Incentives, Rewards, and Recognition The head of each department of agency is authorized to incur whatever necessary expenses involved in the honorary recognition of subordinate officers and employees of the government, who by their suggestion, invention, superior accomplishment, and other personal efforts contribute to the efficiency, economy or the other improvement of government operation, or who perform extra ordinary acts or services in the public interests in connection in their official employment. Outstanding Public Official and Employee or Dangal ng Bayan Award This award is conferred to an individual or performance of extraordinary act of public service and consistent demonstration of exemplary ethical behavior in observance with the eight (8) norms of behavior under RA 6713. e Commitment to Public Interest e Professionalism 267 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Justness and Sincerity Political Neutrality Responsiveness to the Public Nationalism and Patriotism Commitment to Democracy e Simple Living Gender and Development Gender and Development aims to address the various gender needs and concerns of employees in the Commission and Bureaucracy. It includes formulation and implementation of policies and programs addressing women issues and concerns in the public sector. Policy Development and Strengthening Administrative rules are part of the commitment to provide a work environment to support productivity, where all officials and employees are treated with dignity and respect Issuance of Memorandum Circulars on the following: e Policy at work place (MC 33 s. 1997) e Health Awareness Program (MC 38 s. 1992) e Project Talaan and Checklist of Reasonable Working Conditions (CSC MC 30s. 1994) Special Leave Privileges (CSC MC 6 s. 1996 and MC 6 s. 1999) Flexible Working Arrangements (MC 14 s. 1989) Modified Maternity Leave (Sec. 4, Rule XVI of The Omnibus Rules) Policy on Sexual Harassments in the Workplace (CSC Res. #95-6161, MC 19s. 1994) Program to Institutionalize Meritocracy and Excellence

• Human Resource Management (PRIME-HRM) The Civil Service Commission (CSC) which is the central personnel manager of Philippine public agencies mandated the implementation of PRIME-HRM, an acronym for “Program to Institutionalize Meritocracy and Excellence in Human Resource Management,” through CSC Memorandum Circular No. 3, Series of 2012 and CSC Resolution No. 1200241 dated February 01, 2012, integrated with the Personnel Management Assessment and Assistance Program (PMAAP) accreditation. The program is used by the CSC to instill meritocracy and excellence in the performance of the human resource management Officers in public service. This will continually capacitate them in terms of their performance, will recognize their best practices and at the same time will be a venue to exchange/share and develop expertise of the Human Resource practitioner which will focus on their four major 268 Hospital Nursing Service Administration Manual

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Human Resources Management functions on RECRUITMENT, SELECTION and PLACEMENT; LEARNING AND DEVELOPMENT; as well as PERFORMANCE MANAGEMENT; and REWARDS AND RECOGNITION. PRIME-HRM consists of three stages. These are the Assess, Assist and Award; in the first stage assess, the CSC representative will visit a government agency office and evaluate the maturity level of agency’s human resource practices, systems and competencies on the four major focus functions, and a data based program will be used to calibrate result which will classify the agency’s maturity as Level I or Transactional HRM, Level II or Process-Defined HRM, Level III or Integrated HRM and Level IV or Strategic HRM. Based on the result of the assessment, the Commission will provide necessary technical assistance and interventions for improvement and of course an award will be given to those agencies who deserve a Human Resource zeal of excellence. The Civil Service Commission (CSC), in support of the government’s commitment to provide efficient and effective public service delivery, has implemented the “Program to Institutionalize Meritocracy and Excellence in Human Resource Management (PRIME-HRM). This programs aims to transform the agencies’ Human Resource Management (HRM) system, competencies and practices to a level of excellence that fosters good governance. The PRIME-HRM’s philosophy. “People Excellence for Service Excellence”, shall serve as guide among government agencies in transforming every government employee into servant hero (Lingkod Bayani) through excellent HR processes. PRIME-HRM Coverage National Government Agencies 1. Department of Health 2. Department of Education 3. Department of Budget and Management 4. Commission on Audit Local Government Units 1. Lungsod ng Dabaw 2. Lungsod ng Makati 3. Lungsod ng Maynila 4. Lungsod Quezon Government-Owned & Controlled Corporation 1. Landbank of the Philippines 2. Bangko Sentral ng Pilipinas 3. Pag-IBIG Fund 4. Government Service Insurance System 269 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care State Universities and Colleges

1. Visayas State University
2. University of the Philippines
3. Western Mindanao State University

Benguet State University PRIME-HRM enables agencies to achieve HR excellence through three steps:

1. Assess .CSC will assess the maturity level of an agency’s competencies, systems and practices in four HRM systems.
2. Assist. PRIME-HRM provides customized technical assistance and development interventions according to the determined needs of the agency.
3. Award. Agencies may vie for special rewards and citations, such as being a center of HR Excellence or the Seal of HR Excellence. 270 Hospital Nursing Service Administration Manual

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Management of Supplies and Equipment 1 6 MANAGEMENT OF SUPPLIES AND EQUIPMENT Introduction Management of supplies, equipment and other resources is an organizational function which integrates people, places, and processes within the built environment with the purpose of sustaining the quality of services and the productivity of the organization. It involves planning, forecasting, ordering, delivery, inspection, acceptance, storage, inventory, distribution, utilization and disposal of hospital supplies, materials and equipment. Part of the control process is the monthly review of the utilization of materials and supplies in the various nursing units. Consumption of supplies and materials should be proportionate to the number of patients served be these in the form of dressings, treatments done, injections given ete. Requisitions of or stocking a large number of supplies and materials should be avoided to prevent pilferage, misuse, or spoilage. A large order is merited when there is a large demand. The Senior Nurse must know the average daily usage and the time required to receive the supplies from the time these were requisitioned. A high turnover inventory is desired. A low turnover is the result of poor purchasing policies and overstocking of a decreased demand for the item. Ordering the correct materials and checking inventory levels prevent overstocking items that are not frequently used. An equipment utilization report is made, including frequency of breakdown. This will help in evaluating the quality of the equipment purchased, the way it is handled, used or operated. New personnel are taught to use this equipment. New equipment is tested and handled only by personnel trained to use them. Preventive maintenance requires the regular inspection of equipment to prevent breakdown and /or detect needed repairs. Breakdown of equipment results in more expenses and non-productivity of the personnel. Preventive maintenance therefore prevents equipment and process failures. Monthly linen inventory is done to determine the adequacy of linen issued and utilized in the various units. Measures should be instituted to prevent losses. 271 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care Purposes 1. Ensures cost effectiveness 2. Enhances staff productivity 3. Promotes efficient delivery of services Materials, Supplies and Equipment Inventory System Materials, Supplies and Equipment Inventory Management system tracks goods through the entire supply chain. Thus, inventory management is the control of non- capitalized assets (inventory) and stock items. Inventory management is a component of supply chain management that oversees the flow of items (product, goods, etc.) as they move from the materials management supplies services to the end-users. “A key function of inventory management is to keep a detailed record of each new or returned product as it enters or leaves the unit”. Purposes Determines if standards are maintained. Serves as a basis for the revisions of standards and system. Recommends proper action on obsolete and surplus materials Determines the operational status of equipment. Prepares plan for repair and replacement Determines the proper location of supplics, materials and equipment. e Gathers factual information to serve as basis for sound procurement planning. e Ensures continuous customer services. eoeeee ° Definition of Terms Materials are the raw processed items, components, parts, assemblies, sub - assemblies, cleaning agents, and small tolls and accessories that may be consumed directly or indirectly. Supplies refer the quantity of products (goods and services) available for use. Equipment refers to tangible property that is used in the operation and smooth functioning of each nursing unit. Inventory is an administrative tool designed to control supplies and equipment by listing names, description, quantity, locations and balance of supplies. 272 Hospital Nursing Service Administration Manual

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Management of Supplies and Equipment Preventive Maintenance of Equipment The primary goal of each nursing unit is proper recording and reporting of the functionality of all equipment to avoid or mitigate the consequences of failure. It is designed to ensure reliability by replacing worn components before they actually fail. Preventive maintenance requires the regular inspection of equipment to prevent breakdown and or detect needs repaired. It therefore prevents equipment and process failures. Purposes 1. Sustains functionality and reliability of equipment 2. Ensures safety for patients and personnel 3. Maintains good ergonomics Equipment and Supplies Goal The provision of equipment and supplies supports the organization’s role. Standards Planning of facilities, selection, acquisition of equipment/supplies involve input from relevant staff are undertaken by appropriately - qualified personnel. Criteria e Appropriate equipment and supplies that support the organization’s role and level of service are provided. Consideration is given to, at least: o the intended use ° cost o infection control o safety o waste segregation/ disposal and o storage e Specialized equipment are operated according to specifications and only by appropriately trained staff. e Items designated by the manufacturer for single use are not reused unless the organization has specific policies and guidelines for safe reuse which take into consideration relevant statutory requirements and code of practice. Implementing Policies e Equipment and supplies are obtained from CSR and Property Section e All unit supplies and equipment are recorded and accounted for in periodic inventories. 273 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Care of all supplies and equipment are expected from all employees at all times. e Lending o To other hospitals only with the approval of the Medical Center chief. o Supplies and equipment loaned out to other wards and department s are with war’s Slip. Corresponding Borrower’s Slip. o The borrower will be held responsible for the repair (if necessary) and return the item. e Requisition o Routine requisition to Materials Management and Procurement Supply Section are done depending on the institutional policy on stock positioning and ordering time o Routed from Senior Nurse; countersigned by the Supervising Nurse, then to the Chief Nurse Patients/ relatives are not allowed to borrow equipment for home use. Guidelines in the Management of Supplies and Equipment e Equipment should be checked every shift to ensure that it is in good working condition. e Each personnel using particular equipment must understand its operation, purpose and care after use. e Standards must be set relative to the quality and kind of supply and equipment kept in a unit based on the following: o Clinical service o Needs of patients o Bed capacity o The need and demand at any given time due to high rate of patient turnover. o Frequency of items used in emergency situations. e All wards must follow the hospital policy in the requisitioning, repair/disposition of equipment and supplies. e Methods of control must be developed to avoid supplies and equipment mouse, overstocking, extravagance and wastage. Inventory It is an administrative tool designed to control supplies and equipment by listing the names, description, numbers and locations of supplies. Purposes of Inventory e Determines if standards are maintained; e Serves as basis for the revisions of standards and systems; 274 Hospital Nursing Service Administration Manual

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Management of Supplies and Equipment e Recommends proper action on obsolete and surplus materials; e Determines the operational status of equipment; e Prepares plan for repair and replacement; e Determines the proper location of supplies, materials and equipment; and e Gathers factual information to serve as basis for sound procurement planning. Kinds of Inventory e Perpetual Inventory. recording is done as soon as supplies were used and replenished, thus, indicating the number of supplies on hand at a time; e Physical Inventory is the actual count made at designed intervals to correct accumulative errors resulting from loss, breakages or deterioration. Fixed equipment are usually inventoried annually; movable equipment, monthly; instruments, weekly; and narcotics, daily. A capital equipment inventory is an itemized list of current capital assets that enumerates each piece of capital equipment, together with the items’ serial number, current valuation and physical location. When a new item of capital equipment is purchased for a department or unit, it should be listed in the capital inventory. If the new item replaces an outmoded piece of equipment that has been removed from the unit, donated to another agency, the older equipment and its serial number should be removed from the capital equipment inventory to prevent confusion in equipment monitoring. Supply or stock inventory lists are needed to implement the operating budget for each unit. Most health agencies provide operating managers with an agency formulary, a medical supplies stock list, and linen supplies list. Each supply inventory list enumerates, by name, type and size and all supplies available for use in agency. In some agencies movement of supplies is closely monitored. If there is unexpectedly heavy use, depleting supply of a particular item, report is circulated to notify operating managers that the item is temporarily unavailable (Refer to DOH Hospital Property and Supply Management Manual). NOTE: The Senior Nurse of the unit is accountable for all the equipment received Jrom the Material Management Section (Refer to Appendix T Nursing Office Requirements). Procedure of Inventory e The first thing you should do when getting your office supply inventory under control is to limit the access to the supply closet. While open supply rooms may be a convenient option—allowing employees to retrieve supplies as they need them-—it is an inefficient method when trying to keep the storeroom under control. Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e The first issue in regard to an open supply closet is tracking. When anyone can they need at any time, those managing the supplies lose the ability to know what is on hand at any given time. e Making one person (or a small team of people) responsible for dispensing hospital supplies allows your hospital to keep an accurate inventory. It also prevents shrinkage (stealing) and keeps employees from taking more than they actually need. Written Procedure Having a written procedure for inventory management can make a big difference in controlling your supply stream. You know who is responsible for tracking hospital inventory and making sure the items you need are there when you need them. Everyone is aware of the details of how the hospital supplies are managed. Most of all, it sets the tone of expectation—that is, it shows that everyone is expected to follow the procedure as it is written. This can also help identify training issues and monitor adherence to policy. Tracking Tracking your inventory is essential to inventory control. Tracking means keeping a log or spreadsheet of what you buy, how quickly it gets used, and how often more is ordered. There are several ways to track your inventory. You can do this manually. through a tracking software. Grouping A method to help tracking is grouping like items together. For example, all the writing implements could be kept together. This makes your supplies easier to find and track. Not only does this help with tracking, but it also the best system for organizing your storage space. This will help eliminate extra time spent looking for the right item. It will also make stocking easier and more accurate. Setting Reorder Point A reorder point for supplies is the same as it is for maintenance supplies, production supplies and product stock—it is the level of inventory that triggers you to order more. When deciding your reorder point, you should take into consideration how much you use of an item and how quickly. You should also account for delivery time and possible delays. Once you know your reorder points, you may want to consider setting up an automated reorder process. Automated reordering can help take a lot of strain off of inventory management by ensuring that your office supply needs will always be 276 Hospital Nursing Service Administration Manual

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Management of Supplies and Equipment met. You can expect timely deliveries and never have to worry if something was forgotten or neglected. Stock Control Deciding how much stock to keep depends on the size and nature of your hospital, and the type of stock involved. Advantages e Efficiency and flexibility e Lower storage costs Stock Control Methods There are several methods for controlling stock, all designed to provide an efficient system for deciding what, when and how much to order. e Minimum Stock Level - you identify a minimum stock level, and re-order when stock reaches that level. This is known as the Re-order Level. e Stock Review - you have regular reviews of stock. At every review you place an order to return stocks to a predetermined level. e Just In Time (JIT) - this aims to reduce costs by cutting stock to a minimum. Items are delivered when they are needed and used immediately. There is a risk of running out of stock, so you need to be confident that your suppliers can deliver on demand. These methods can be used alongside other processes to refine the stock control system. For example: e Re-Order Lead Time allows for the time between placing an order and receiving it. e Economic Order Quantity (EOQ) is a standard formula used to arrive at a balance between holding too much or too little stock. It's quite a complex calculation, so you may find it easier to use stock control software. e Batch Control is managing the production of goods in batches. Make sure that there is the right number of components to cover the needs until the next batch. If the needs are predictable, a fixed quantity of stock may be ordered every time there is a need to place an order, or at a fixed interval, then there is a need to keep the quantities and prices under review. 277 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e First In, First Outis a system to ensure that perishable stock is used efficiently so that it doesn't deteriorate. Stock is identified by date received and moves on through each stage of production in strict order. Stock Control Systems - Keeping Track Manually Stocktaking involves making an inventory, or list, of stock, and noting its location and value. It is often an annual exercise - a kind of audit to work out the value of the stock as part of the accounting process. Codes, including barcodes, can make the whole process much easier but it can still be quite time-consuming. Checking stock more frequently - a rolling inventory - avoids a massive annual exercise, but demands constant attention throughout the year. Radio Frequency Identification (RFID) tagging using handheld readers can offer a simple and efficient way to maintain a continuous check on inventory. Any Stock Control System Must Enable You To e track stock levels e make orders e issue stock Stock cards are used for more complex systems. Each type of stock has an associated card, with information such as: description value location re-order levels, quantities and lead times (if this method is used) supplier details information about past stock history More sophisticated manual systems incorporate coding to classify items. Codes might indicate the value of the stock, its location and which batch it is from, which is useful for quality control. Stock Control Systems— Keeping Track Using Computer Software Computerized stock control systems run on similar principles to manual ones, but are more flexible and information is easier to retrieve. One can quickly get a stock valuation or find out how well a particular item of stock is moving. Management of Supplies adopt the control system of First Expiry First Out (FEFO) and First In First Out (FIFO) 278 Hospital Nursing Service Administration Manual

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Management of Supplies and Equipment A computerized system is a good option for businesses dealing with many different types of stock. Other useful features include: Stock and pricing data integrating with accounting and invoicing systems. All the systems draw on the same set of data, so you only have to input the data once. Sales Order Processing and Purchase Order Processing can be integrated in the system so that stock balances and statistics are automatically updated as orders are processed. Automatic stock monitoring, triggering orders when the re-order level is reached. Automatic batch control if you produce goods in batches. Identifying the cheapest and fastest suppliers. Bar coding systems which speed up processing and recording. The software will print and read bar codes from your computer. Stock Security Keeping stock secure depends on knowing what you have, where it is located and how much it is worth - so good records are essential. Stock that is portable, does not feature the business' logo, or is easy to sell on, is at particular risk. Stock Protection Identify and mark expensive portable equipment (such as computers). If possible, fit valuable stock with security tags - such as Radio Frequency Identification tags - which will sound an alarm if they are moved. Don't leave equipment hanging around after delivery. Put it away in a secure place, record it and clear up packaging. It is a good idea to dispose of packaging securely -leaving boxes in view could be an advertisement to thieves. Take regular inventories. Coordinate with the security service officer for stock protection. Roles of Nursing Leaders Maintaining may be essential part of a job as a nurse leader. Developing a strong relationship with Material Management Department, taking advantage of the capabilities of digital inventory control. 21D Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care e Make the most of your facility’s inventory software. e Use the report function to determine when expiration dates are approaching or track the items you use the most. e Developing a rapport with Material Management Staff can be beneficial. e Invite the staff to observe your nursing units and make recommendations for improving inventory management. e Take advantage of Just-In Time Ordering if space in your supply area is limited, ask your Material Management Department if you can use Just-In Time Ordering this can help ensure you have the supplies you need when you need them. Take a look at typical usage for each item per week or bi-weekly. When you place orders weekly or bi-weekly, you won’t overstock your supply area or waste money by ordering bulk products that are never actually used. e Reorganized your supply closet/cabinet sometimes it seems as if supplies just disappear, even though your inventory software insists you still have them. Although theft can be a problem in some cases, the missing supplies may actually be pushed behind seldom-used items. Solve the problem by placing items frequently used together, like your topical anesthetic and IV start kit, close to each other. If all of the supplies required to perform a procedure are located in one place, your nurses won’t have to rummage through your closet looking for the things they need. Color-coding item labels can also make finding supplies easier. e Double-check Orders - appoint a staff member to check every order you receive from materials management. Don’t just assume orders are correct. Physically count every item noted on the packing list and compare it to your original order. 280 Hospital Nursing Service Administration Manual

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Hospital as People-Centered Health Care 1 7 HOSPITAL AS PEOPLE- CENTERED HEALTH CARE Introduction The people-centered health care is an umbrella term that better encapsulates the foremost consideration of the patient across all levels of health systems. It also covers the concept of the patient-centered health care.Therefore, the people-centered care goes beyond a model or care that confronts common epidemiological population profiles to one that considers holistic needs and aims of the community in an evolutionary movement that should strengthens individuals and communities’ competencies and action towards health and well-being. People-Centered Care means designing and delivery health services that meet the needs of people not disease or healthcare workers, where people are informed. engaged, supported and treated with dignity and compassion and means enabling health providers to create enduring and trusted relationships with patient, families, and communities. The Integrated People-Centered Health Services (IPCHS) is rooted in the country’s commitment at the 69th World Health Assembly (WHA) and at the 31st ASEAN Summit held in 2016, and in 2017, respectively. The WHA Issuance No. 69.24 urges member states to implement the IPCHS framework, proposed policy options and interventions, in accord with the national context and priorities on universal health coverage, emphasizing on primary care. To build on its foundation fosters a people-oriented and people-centered region. Executive Order No. 5, series of 2016, emphasizes this commitment — the vision of Filipinos to enjoy a strongly rooted, comfortable, and secure life by 2040. To fulfill this, the Philippine Development Plan for 2017 to 2022 calls for enhancing the social fabric (malasakit) for a people-centered, clean, and efficient government. The Department of Health (DOH), through the FOURmula One Plus for Health (F1+), envisions Filipinos as “among the healthiest people in Asia by 2040 with a productive, resilient, equitable, and people-centered health system for universal health care.” Finally, in February 2019, Republic Act 11223, or the Universal Health Care Act (UHC), adopts approaches to ensure that all Filipinos are health literate, living in 281 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care healthy conditions, protected from health-affecting hazards and risks, with health services centered on people’s needs and well-being. This Administrative Order provides for the healthcare system an avenue to be cognizant of the differences in culture, values, and beliefs. Objective This Order provides the framework that shall guide national and local actions towards the institutionalization of integrated people-centered health services in all health facilities. Potential Benefits of People-Centered and Integrated Health Services To the Individuals and their Families e increased satisfaction with care and better relationships with care providers e improved access and timeliness of care e improved health literacy and decision-making skills that promote independence e shared decision-making with professionals with increased involvement in care planning e increased ability to self-manage and control long-term health conditions e better coordination of care across different care settings. To Communities e improved access to care. particular for marginalized groups e improved health outcomes and healthier communities, including greater levels of health seeking behavior e better ability for communities to manage and control infectious disease and respond to crises e greater influence and better relationships with care providers that build community awareness and trust in care services e greater engagement and participatory representation in decision-making about the use of health resources e clarification on the rights and responsibilities of citizens to health care e care that is more responsive to community needs. To Health Professionals and Community Health Workers e improved job satisfaction fi improved workloads and reduced burnout e role enhancement that expands workforce skills so they can assume a wider range of responsibilities e education and training opportunities to learn new skills, such as working in team-based health care environments. 282 Hospital Nursing Service Administration Manual

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Hospital as People-Centered Health Care To Health Systems enables a shift in the balance of care so that resources are allocated closer to needs improved equity and enhanced access to care for all improved patient safety through reduced medical errors and adverse events increased uptake of screening and preventive program, improved diagnostic accuracy and appropriateness and timeliness of referrals reduced hospitalizations and lengths of stay through stronger primary and community care services and the better management and coordination of care reduced unnecessary use of health care facilities and waiting times for care reduced duplication of health investments and services fi reduced overall costs of care per capita reduced mortality and morbidity from both infectious and non-communicable diseases. The Key Characteristics of People-Centered Health Care includes: For Individuals, Patients and their Families: Access to clear, concise and intelligible health information and education that increase health literacy; Equitable access to health systems, effective treatments, and psycho-social support; Personal skills which allow control over health and engagement with health care systems: communication, mutual collaboration and respect, goal setting, decision making, and problem solving, self-care; and Supported involvement in health care decision-making, including health policy. For Health Practitioners: Holistic approach to the delivery of health care; Respect for patients and their decisions; Recognition of the needs of people seeking health care; Professional skills to meet these needs: competence, communication, mutual collaboration and respect, empathy, health promotion, disease prevention, responsiveness, and sensitivity; Provision of individualized care; Access to professional development and debriefing opportunities; Adherence to evidence-based guidelines and protocols; Commitment to quality, safety and ethical care; Team work and collaboration across disciples, providing coordinated care and ensuring continuity of care. 283 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care In Health Systems: e Primary care serves as the foundation; e Financing arrangements for health organizations that support partnership between health practitioners and people accessing health care; e Investment in health professional education that promotes multidisciplinary team work, good communication skills, an orientation towards prevention, and integrates evidence about psychosocial dimensions of health care; Avenues for patient grievances and complaints to be addressed; Collaboration with local communities; Involvement of consumers in health policy; Transparency Key Principles in People-Centered Care Promotion of health and wellbeing Focus on whole-person care Care for all people Partnership and participation Sensitivity to social/cultural diversity and context Quality of relationship and communication between the system and users Tailored and responsive care — i.e. to individual needs Comprehensive Continuous Right and responsibilitics People-Centered Health Services Is an approach to care that consciously adopts the perspective of individual, families and communities, and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. It requires that people have the education and support they need to make decisions and participate in their own care. It also organized around the health need and expectations of people rather diseases (WHO). As An Integrated Health Services They are health services that are managed and delivered in a way that ensures people to receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and Palliative care services at the different levels and sites of care within the health system and according to their needs throughout their life course. 284 Hospital Nursing Service Administration Manual

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Hospital as People-Centered Health Care Perspectives in Quality Health Care that is: e Effective — delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need; e Efficient - delivering health care in a manner which maximizes resource use and avoids waste; e Accessible/timely- delivering health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical need; e Acceptable/Patient-Centered- delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities; e Equitable- delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status; e Safe- delivering health care which minimizes risks and harm to service users Core Principles of People-Centered Services e Comprehensive e Equitable e Sustainable ¢ Coordinated e Continuous Holistic Preventive Empowering Respectful Collaborative Co-Produced Endowed with rights and responsibilities Governed through shared accountability Evidenced-based Led by whole-systems thinking Ethical Putting People at the Center The global framework of the World Health Organization is accepted regionally to implement the people-centered health care strategies. 1. Empowering and engaging people and communities 2. Strengthening governance and accountability 285 Hospital Nursing Service Administration Manual

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The Management in the Delivery of Nursing Care 3. Reorienting the model of care 4. Coordinating services within and across sectors; and 5. Creating an enabling environment The attainment of these five strategies cumulatively will help to build more effective health services: lack of progress in one area will potentially undermine progress in other areas. 286 Hospital Nursing Service Administration Manual

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REFERENCES Administrative Order 2018-0014 or The Strategic Framework and Implementing Guideline for FOURmula One Plus for Health (F1+) De Belen, Rustico T. and Buhat, Maria Linda G. Nursing Leadership and Management, A Breakthrough Approach (2014), First Edition, Quezon City, ANSAP, Inc. Jones, Rebecca A. Patronis (2007). Nursing Leadership and Management Theories, Processes and Practice, F.A. Davis Company. National Standards in Infection Control for Healthcare Facilities, 2009 Swansburg, Russell C. (1990). Management and Leadership for Nurse Managers, Jones and Bartlett Publishers, Inc. Tomey, Ann Mariner (Guide to Nursing Management and Leadership 8" Edition) Internet Sources: https:/Avww.scribd.com-mobile.doc. Accessed: 10/3/17 at 2:00pm https://www.slideshare.net (Miya Rayo, April 12, 2013). Accessed: 10/3/17 at 3:00pm isarevad.weebly.com.nursing-management (September 29, 2012). Accessed 10/4/17 at 3pm Nursing Management Function: The Planning Phase-Leadership. https://www.slideshare.net.ballplayer 23 (July 27, 2012) https:www.sheffield.ac.uk.collecting. accessed: 10/8/17 at 4:30pm https://www.slideshare.net.bivinjose. (Feb, 2014) accessed: 10/23/17 at 5:00pm https://en.m.wikipedia.org *Gantt. Accessed 10/31/17 at 8:00pm https:/Avww.strategicmanagementinsight.com. Accessed 10/31/17 at 9:00pm calswec.berkely.edu.toolkits.planning. accessed: 10/17/17 at 1:00pm nmdfa.state.nm.us.Steps in Planning.accessed: 10/4/17 at 10:30am www.investopedia.com (Steven Nicolas, 4/22/15) accessed: 10/4/17 at 3:00pm umsl.edu projectmanagementtools and technique. (Sean Maserang,2002), accessed:10/23/17 at 9:00pm kullabs.com. accessed: 10/4/17 at 10:30am linkendin.com. accessed 10/16/17 at 6:00pm faculty.ksu.sa.Hanan_Alkorashy. Accessed:10/24/17 at 4:00pm http://www.officialgazette.gov.ph/2016/08/15/memorandum-circular-no-3-s-2016/ https:// www.sumhr.com 9/27/17 287

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http:www.hrwols.com performance mgt-appraisal Method 9/27/17 http:// Managementstudyguide.com MSG Management and Leadership for Nurse Managers, Russel C. Swansburg, Richard J. Swansburg, 3 edition. http:// currentnursing.com/nursing- management/documentation.html http:/Awww.cliffnotes.com Wikidiff.com>recording > reporting Fundamentals of Nursing. Patricia A. Potter, Anne Griffin Perry, 6" edition, Elsevier Mosby. (Cited From http:// currentnursing.com/nursing -management/documentation.html) https://www.instituteofcustomerservice.com/research-insight/guidance-notes/article/handling- complaints “Leadership and Nursing Care Management”; Functional Nursing; Diane Huber, RN PhD; 2006) Modalities of Nursing Care, Fundamental of Nursing; September 3, 2011 Career Trend; Aunice Reed; updated june 6, 2017 Essentials of Nursing Leadership and Management; Second Edition; Patricia Kelly, Proffesor Emeritus, Purdue University Calumet Hammond, Indiana, 2010 Hospital Nursing Service Administration Manual-DOH: 2009 International Conference on Harmonization Guideline Quality Risk Management 2005 Harvard Business Review “Creating a Culture of Quality April, 2014” International Organization for Standards (ISO) 9001-2015 — Quality Management Systems — Requirements Benchbook on Performance Improvement of Health Services. Philippine Health Insurance Corporation. 2004. Civil Service Commission Handbook on Personnel Discipline. Cleland, D.I. and Harold Kerner, A Project Management Dictionary of Terms Department of Health. NCHFD & PHICS. Standards in Infection Control for Healthcare Facilities. Manila. 2005. Department of labor and Employment Employees’ Compensation Commission. The Worker’s Compensation. Manila. 2006. De Belen, Rustico and Loarca, Josefina. A Handbook in Nursing Law and Ethics. 1* edition. ARD Publishing House. 2006. 288

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Ebright, P., Patterson, E. Challo, B. and Render, M. “Understanding the Complexity of Registered Nurse in Acute Care Settings”. JONA, Vol. 33, No. 22, pp 630-638. 2003. The Philippine Professional Nursing Practice Standards (Professional Regulation Commission Board of Nursing. Department of Health. HHRDB Manual. Job Description. Hospital Nursing Service Administration Manual. DOH. 2" edition, 1994. Kelly, Heedenthal, Patricia. Essentials of Nursing Leadership and Management Singapore: Thomson Learning Asia. 2005. Maramba, N., & Panganiban, L.C. Algorithims of Common Poisonings: Part I Philippines: National Poison Control and Information Service Mc Clelland, DBL, Walsh T. “The Effective and Safe Use of Blood Components”. Practical Transfusion Medicine. Blackwell Publishing Oxford. 2005. Pp. 67-85. National Formulary Committee. Philippine National Drug Formulary, vol. 1. 6" ed. 2005. Venzon, Lydia M. and Jennifer M. V. Nagtalon. Nursing Management Towards Quality Care. C & E Publications, Manila. 2006. Patient Safety Program Manual. AHRQ and Veterans Administration World Health Organization. Practical Guideline for Infection Control in Health Care Facilities. India. 2004. 289

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APPENDICES 291

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293 APPENDIX A KOTTER’S 8-STEP CHANGE MODEL Implementing Change Powerfully and Successfully Step 1: Create Urgency For change to happen, it helps if the whole company really wants it. Develop a sense of urgency around the need for change. This may help you spark the initial motivation to get things moving. This isn't simply a matter of showing people poor sales statistics or talking about increased competition. Open an honest and convincing dialogue about what's happening in the marketplace and with your competition. If many people start talking about the change you propose, the urgency can build and feed on itself. What you can do: e Identify potential threats , and develop scenarios showing what could happen in the future. e Examine opportunities that should be, or could be, exploited. e — Start honest discussions, and give dynamic and convincing reasons to get people talking and thinking. e — Request support from customers, outside stakeholders and industry people to strengthen your argument. Step 2: Form a Powerful Coalition Convince people that change is necessary. This often takes strong leadership and visible support from key people within your organization. Managing change isn't enough — you have to lead it. You can find effective change leaders throughout your organization — they don't necessarily follow the traditional company hierarchy. To lead change, you need to bring together a coalition, or team, of influential people whose power comes from a variety of sources, including job title, status, expertise, and political importance. Once formed, your "change coalition" needs to work as a team, continuing to build urgency and momentum around the need for change. What you can do: e — Identify the true leaders in your organization, as well as your key stakcholders. e — Ask for an emotional commitment from these key people. e Work on team building within your change coalition. e Check your team for weak areas, and ensure that you have a good mix of people from different departments and different levels within your company. Step 3: Create a Vision for Change When you first start thinking about change, there will probably be many great ideas and solutions floating around. Link these concepts to an overall vision that people can grasp easily and remember. A clear vision can help everyone understand why you're asking them to do something. When people see for themselves what you're trying to achieve, then the directives they're given tend to make more sense. What you can do: e Determine the values that are central to the change. Develop a short summary (one or two sentences) that captures what you "see" as the future of your organization. Create a strategy to execute that vision. Ensure that your change coalition can describe the vision in five minutes or less. Practice your "vision speech" often. Step 4: Communicate the Vision What you do with your vision after you create it will determine your success. Your message will probably have strong competition from other day-to-day communications within the company, so you need to communicate it frequently and powerfully, and embed it within everything that you do. Don't just call special meetings to communicate your vision. Instead, talk about it every chance you get. Use the vision daily to make decisions and solve problems. When you keep it fresh on everyone's minds, they'll remember it and respond to it.

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294 It's also important to "walk the talk." What you do is far more important — and believable — than what you say. Demonstrate the kind of behavior that you want from others. What you can do: e Talk often about your change vision. e Address peoples' concerns and anxieties, openly and honestly. e Apply your vision to all aspects of operations — from training to performance reviews. Tie everything back to the vision. e Lead by example. Step 5: Remove Obstacles If you follow these steps and reach this point in the change process, you've been talking about your vision and building buy- in from all levels of the organization. Hopefully, your staff wants to get busy and achieve the benefits that you've been promoting. But is anyone resisting the change? And are there processes or structures that are getting in its way? Put in place the structure for change, and continually check for barriers to it. Removing obstacles can empower the people you need to execute your vision, and it can help the change move forward. What you can do: e Identify, or hire, change leaders whose main roles are to deliver the change. e Look at your organizational structure, job descriptions, and performance and compensation systems to ensure they're in line with your vision. e Recognize and reward people for making change happen. e — Identify people who are resisting the change, and help them see what's needed. e Take action to quickly remove barriers (human or otherwise). Step 6: Create Short-Term Wins Nothing motivates more than success. Give your company a taste of victory early in the change process. Within a short time frame (this could be a month or a year, depending on the type of change), you'll want to have some "quick wins " that your staff can see. Without this, critics and negative thinkers might hurt your progress. Create short-term targets — not just one long-term goal. You want each smaller target to be achievable, with little room for failure. Your change team may have to work very hard to come up with these targets. but each "win" that you produce can further motivate the entire staff. What you can do: ¢ Look for sure-fire projects that you can implement without help from any strong critics of the change. e Don't choose early targets that are expensive. You want to be able to justify the investment in each project. e Thoroughly analyze the potential pros and cons of your targets. If you don't succeed with an early goal, it can hurt your entire change initiative. e Reward the people who help you meet the targets. Step 7: Build on the Change Kotter argues that many change projects fail because victory is declared too early. Real change runs deep. Quick wins are only the beginning of what needs to be done to achieve long-term change. Launching one new product using a new system is great. But if you can launch 10 products, that means the new system is working. To reach that 10th success, you need to keep looking for improvements. Each success provides an opportunity to build on what went right and identify what you can improve. What you can do: e After every win, analyze what went right, and what needs improving. Set goals to continue building on the momentum you've achieved. Learn about kaizen , the idea of continuous improvement. Keep ideas fresh by bringing in new change agents and leaders for your change coalition. eee Step 8: Anchor the Changes in Corporate Culture Finally, to make any change stick, it should become part of the core of your organization. Your corporate culture often determines what gets done, so the values behind your vision must show in day-to-day work.

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295 Make continuous efforts to ensure that the change is seen in every aspect of your organization. This will help give that change a solid place in your organization's culture. It's also important that your company's leaders continue to support the change. This includes existing staff and new leaders who are brought in. If you lose the support of these people, you might end up back where you started. What you can do: e Talk about progress every chance you get. Tell success stories about the change process, and repeat other stories that you hear. e Include the change ideals and values when hiring and training new staff. Publicly recognize key members of your original change coalition, and make sure the rest of the staff — new and old — remembers their contributions. e Create plans to replace key leaders of change as they move on. This will help ensure that their legacy is not lost or forgotten.

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education and in-service traini ig skills e Institutionalization of special Trainors 2019-2024 2019- 2024 Coordinators CN, Coordinators STRATEGIES/ PERSON/S OBJECTIVES ACTIVITIES TARGET TIME FRA, RESPONSTRLE RESOURCE INDICATOR

for fellows 1 supervisor

for affiliates 1 supervisor No. and percentage of continuing e Scheduling continuing All nurses e Regular nursing audit e Monitoring/Supervision All ward super’ CN, Ti Coordinators, Supervisors Nursing audit (done)

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UOISIAIG S9IAI9g BUISINN Jory duind oose3uey dol Joye] WUD A, 4OZ1[NQON sioylamodA3 Z Aiojyesoge| quowidinbs jo yuaWIoIND01g ONUdA SulUlel] pup juamdmnba aynbapy jyuowdinba pue sjeiioyeur ajenbape jo uolstAoig Sonjea |eIOU pue jenjiids e wioysXs yloddns poos jo Surmoys e SUONDUNY /SOJO JO MOIADY ayes SULIO. suiuiely ‘NO AIDUIT]D 1D1I0S poor) | [BId0S poos uay}3uea}¢ ATMISNOdSAY SALLIAILOY YOLVIIGN aounosa) an QUAL Si Oar I ay S/NOSUAd AWag ANIL /SAIDALVULS sae oO 662

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300 SAMPLE OF OPERATIONAL PLAN 2019 OBJECTIVES TARGET STRATEGY ACTIVITIES FRA BUDGET RESPONSIBLE INDICATOR the clientele and healthcare team health outcomes Manual PJGMRMC reproduction and July to Sept. 1 copy — Training and Acceptable Formulate Implementa: J Php Chief Nurse Training conducted standards of DOH Circular on December 500,000.00 Hospital Quality

Increase in number of beds nursing care personnel/ pa 2019 Assurance siderails personnel’s safety Committee

• Nursing Personnel with safety -Training/ MANCOM complete immunization esp. Orientation Representatives in OR, Special areas ff beds with side chairs with lock Exam theff: from all levels of Infection Control Nurse Senior Nurses Supervisors ACN

Decrease in incidence of Sa related activities from 5

• 0

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302 OBJECTIVE STRATEGY or objective describing the observation at the Response — patient machines 30 Non-mercurial supplies in the Purchase OR, ER

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109 LAW Surures |, — poo AQ] [Je Ie pooyoo-o4 saeuLUas yjuow 6107 juowdojoaop Suture oy) popuoye dod s8urure.y Jaquiss0q Jouuosiod juawidojaaap oyM jouuosiod Suisunu ZO} | seo] 0) Asenues pue Jooiwo | jyeys 40} UOTRONps LfO WoMIopuN /payudL0 1 YUM (OO'T wo AWAQOR wieisoid suinunuod yuowdojaaop jye}s jouuosiad pajouioid AjMou OSINN JOLY, ssoyeads 105 Ay yuour suinuyuos /Bururey golf | 10) weassoad uoyesnpa Zummuyuos PUR sjuRA}Ud MOU JO %IO | yeas Sururesy, winleJOUO}H] poynpayos {OM B ysiqeisq OY) UO/UO}RIUSLIO 40/pue Surrey apiaoad/janpuos YOLVOIGN] ATHISNOdSAy

. , a . " " JONVAUONIE s/NOSwag sLaoang AINVUY FIAT, SALLIALOW ADALVULS LADUV L SHALLOALIO €0€

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304 OBJECTIVES TARGET STRATEGY ACTIVITIES FRAME BUDGET 300/ DOTS Management: Exercises Career path for Develop Clinical Ladder On-going c/o nursing All Nursing 60% of nursing personnel nursing personnel clinical for Nursing quarterly personnel for | personnel competed the required pathway for Practice classified | evaluation/ personal seminars/training practitioners Novice Advance B. nner Establish standard Ensure Compute for the Standard

of

41.30% of the number of work and day sufficient staff needed of Nursing nursing personnel for a 400 patterns for staffing to patients units of 2019 Personnel for bed capacity in a tertiary NA’s/RN’s to cover all the hospital 400 bed hospital is achieved 58.70% improve shifts, off wherein the total capacity needed information duties, number of Tertiary

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306 OBJECTIVES TARGET PERSON/S behavior based supervisor skills enter and early childhood learning premises for those Revenue Enhancements PGP 2019 Training Staff NSO funds care Start the day with a Smile. Be a Good Doing the right Ko.” “Ang kadamu sang maibitar pero ang | | 2019 10,000 Quality Assurance Committee Committee

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ayyut ADALVULS LOE

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308 (This page is intentionally left blank.)

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309 APPENDIX D SAMPLE MITIGATION PLAN FIRE EMERGENCY CONTINGENCY PLAN In the event of a fire in the hospital, the following contingency plan will be put into action. At the time that a fire is discovered, the following procedures should be followed: 1. 2. Call 911 immediately and report the fire. Notify the department ER Team Leader or Department Supervisor, known as the Person-In Charge (PIC). The fire should be inspected by the person notified in 2 and that person will decide whether the building should be evacuated. In the case of a minor fire, all personnel in the area subject to smoke inhalation should be evacuated The PIC will attempt to extinguish the fire. If the fire is not minor, or is not extinguishable by the PIC, he or she will be responsible for signaling the fire alarm and evacuating their department. All employees should be evacuated from the building and gather at the designated emergency meeting area. In the event of a fire, or any other emergency, elevators should not be used.

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310 APPENDIX E SAMPLE COMMUNICATION PLAN

• Meeting evaluation members Patient/Famity |- Existing issues with | Face-to-face | Quarterly (during | Second Tuesdayof | yom tesder form feedback advisory board the triage process meeting board meetings) jeach quarter at 1 p.m!
• Survey at end of project
• Existing issues with «Gre Gibiw ED « Patient /farnily Weekly written we Submitted bynoon | yoo, eee coat manager complaint history report on Fridays :
• Survey at end of
• Triage process ect benchmarks proj » Existing issues with ED care tearm the triage process
• Meeting evaluation (doctors, |* Patient/famity Face-to-face | Weekly (during staff} At the start of each Pe te se form feedback " patra ay pes compisint history meeting meetings} shift on Thursdays eamteader |. Survey at end of « Triage process project benchmarks
• Purpose of project team ED non-care team |+ Announcement of seats: besrde Atcompletion of | Within 72 hours of | resm scribe | foe oe “ members protest eee -aieuin ent | Malior milestones | milestone approvai of project} members
• Purpose of project Other hospital staff; team ¥ ~ =, = Email request for potentially affected | - Announcement of At completion of | Within 72 hours of ” “ by triage process | project team Email message | major mitestones | milestone approval | Teamscribe | feedback (issued at changes formation and oN

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%001-99 quoutked-09 osury 010Z YIM syjuoed % LT16 HOOT.

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312 NBB-eligible patients. 98.23% Numerator: No. of NBB-eligible patients with zero co-pa. ut Range Range ER 94% 96% 98% | 100% me % | defined as No.of ER Pati it: 4 Tr ‘ received in 0. of ‘atients wi h < 4hours urnaround Time x 100% Level 2: | the ER up . Total number of patients who were received inthe ER 95.66% | to the Indicators. 96% 98% 99% 100% patient is % of ER Patients ena sae d/ with < 4 hours The percentage of ER patients who were processed (received, given service and discharged) Turnaround Time released from the ER) within < 4 hours among all the patients who w: a Numerator: No. of ER Patients with < 4 hours Turnaround Time a Denominator: Total number of patients who were received in the ER Tsvel 3: ne actual 90% 92% 94% 96% | eign physical 60-100% the patients this indicator,

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314 PGS Three hospitals PGS Four Internati onal accredita tion: Two hospitals Indicator 6. Total number of inpatients who had Hospital Acquired Infection after Total number of discharges and deaths occurring after 48 hours x 100 The percentage of inpatients who acquired an infection after 48 hours upon the hospital in the whole year among all the number of discharges and deaths
occurred after 48 hours upon admission of the patients. Numerator: Total number of inpatients who had Hospital Acquired Infection ajier 4 Denominator: Total number of discharges and deaths occurring afier 48 hours upon admission during the same year <1% <2% <1% 1.26% <2% <1%

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316 8 10 12 Level 3- 15 Range 0-1 6,95 7 Range 0-41 iis presented in an or Indicators publicly reported (online) Report, OPCR, Hospital Scorecard, PBB, CSS Report) For 2021- At least 4 out of 5 reports are posted (i.e. Annual Hospital Siatistical Hospital Scorecard, PBB, CSS Report) For 2022- At least 5 out of 5 reports are posted (i.e. Annual Hospital Statistical Report, OPCR, Hospital Scorecard, PBB, CSS Report) Numerator: No. of reports of the previous year, such as Annual Hospitcil 100% Annual posted online 60% 80% 100% 95, 75%6 the ebsites 1S"of March of the ear. e.g. 2018 IAHSR must 2019)

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318 APPENDIX G SAMPLE WISN ANALYSIS AS BASELINE FOR DECISION-MAKING Staff Category: Midwife in a health centre in Wisnela province Health Centre Current Staff Required Staff, based on WISN |_ Shortage or Excess Workforce Problem WISN Ratio Workload Pressure A 2 4 -2 Shortage 0.5 High D 6 6 0 Balance 1 Normal

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319 APPENDIX H DOH MEMORANDUM CIRCULAR NO. 2016-0032 Republic of the Philippines Department of Health OFFICE OF THE SECRETARY 16 August 2016 MEMORANDUM CIRCULAR No. 2016 -__0032 FOR: SUBJECT: ALL _UNDERSECRETARIES, ASSISTANT SECRETARIES: DIRECTORS OF BUREAUS, _REGIONAL ___ OFFICES, SERVICES AND SPECIALTY HOSPITALS; CHIEFS OF MEDICAL CENTERS AND HOSPITALS, TREATMENT AND REHABILITATION CENTERS; PRESIDENT OF THE PHIL. HEALTH_INSURANCE CORPORATION AND EXECUTIVE DIRECTORS OF PHIL, NATIONAL AIDS COUNCIL AND THE PHIL INSTITUTE OF TRADITIONAL AND ALTERNATIVE HEALTH CARE __(PITAHC), NATIONAL _ NUTRITION COUNCIL, COMMISSION ON POPULATION (POPCOM) AND OTHERS CONCERNED Memorandum Circular No. 3 dated 8 August 2016 entitled “Enjeining All Government Officials and Employees to Strictly Observe and Comply with the Required Work Heurs” Att “Enjoining All Gov 2016 enti 1 Comply w s emorandum Circular No. 3 dated & Aug nt Officials and Employees to Strictly Obse: the Required Work Hours” from the Office of the President for your ready reference. For information and guidance of all concerned. em MALACANANG-08-394 By Authority of the Secretary of Health: Direofor IV, HHRDB Officer-in-Chgrge, Assistant Secretary Office for Policy and Health Systems KENNETH G. ae na MPHM, CESO HI Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila £003 © Trunk Line 651-7800 focal 1413, 1108, 1135 Direct Line: 711-9502; 711-9503Fax: 743-1829 * URL: hittyi//vww.doh.goy.ph; e-mail: officeofsah@doh.gov.ph

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320 @ffice of the President of the 3bilippines filalacafiang MEMORANDUM CIRCULAR NO. 93 ENJOINING ALL GOVERNMENT OFFICIALS AND EMPLOYEES TO STRICTLY OBSERVE AND COMPLY WITH THE REQUIRED WORK . HOURS WHEREAS, Section 2 of Republic Act No. 6713, otherwise known as the "Code of Conduct and Ethical Standards for Public Officials and Employees,” provides that it is the policy of the State to promote a high standard of ethics in public service and requires government personnel to discharge their duties with utmost responsibility, integrity, competence, and loyalty, act with patriotism and justice, lead modest lives, and uphold public interest over personal interest; WHEREAS, Rule XVII of the Omnibus Rules Implementing Book V of Executive Order (EO) No. 292 (s. 1987) (Omnibus Rules) states that each head of the department or agency shall require all officers and employees under him to strictly observe the prescribed office hours through a daily time record of attendance of all the officers and employees under him, including those serving in the field or on the water; WHEREAS, Section 5, Rule XVII of the Omnibus Rules, provides that officers and employees of all departments and agencies except those covered by special laws shall render net less than eight (€) hours of @ day for five (5) days a week or a total of forty (40) hours a week, exclusive of time for lunch, which as a general rule, shal! be from 8:00 a.m. to 12:00 n.n. and from 7:00 p.m. to 5:00 p.m, on all days except Saturdays, Sundays and Holidays; WHEREAS, Section 6, Rule XVII of the said Omnibus Rules, states that flexible working hours may be allowed subject to the discretion of the head of department or agency, provided that the weekly working hours shall not be teduced in the event the department or agency adopts the flexi-time schedule in reporting for work; WHEREAS, Section 46 (b), Chapter 7, Subtitle A, Title 1, Book V of EO No, 292 considers neglect of duty, inefficiency in the performance of official duties, loafing or frequent unauthorized absences from duty during regular office hours, and conduct prejudicial to the best interest of the service as grounds for disciplinary actions;

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WHEREAS, it has been reported that many government officials and employees have been remiss in their obligation to render the required government work hours; NOW THEREFORE, in order to ensure the observance of the highest ethical standards among public officials and employees, the following are hereby ordered:

1. All government officials and employees shall strictly observe and comply with all pertinent laws, issuances and policies concerning work hours. They are prohibited from taking extended lunch breaks and spending time outside the office doing unauthorized and non-work related activities during office hours.
2. Ail heads of departments, bureaus and offices, government-owned or -controlled corporations and local governments, including the AFP and the Philippine National Police, shall remind and reiterate to the officials and employees under them the above-stated matters and impose the appropriate sanctions and penalties in case of violation thereof, This Order shall take effect immediately. DONE, in the City of Manila, this sth dayof August in the year of Our Lord, Two Thousand and Sixteen. By Authority of the President: 1c SALVADOR C. MEDIALDEA Executive Secretary cnn nist SMa CERTIFIED COPY: MARIANITS M4, BY DRECTOR 321

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322 APPENDIX I SAMPLE MASTER ROTATION PLAN - MATRIX Name of Employee Year Month Jan Feb Mar Apr May Jun | Jul Aug Sept Oct Nov Dec

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323 APPENDIX J SAMPLE MASTER STAFFING PATTERN ILOCOS TRAINING AND REGIONAL MEDICAL CENTER San Fernando City, La Union NURSING SERVICE DIVISION Clinical and Patient Care; Training, Research and Development Staffing/ Staff Distribution . Bed 5 . ; sae Nursing Unit Capacity Nurse IV | Nurse If | Nurse II Nurse I Midwife Attendant Emergency 3 Reon 100

4 13 3COS 2 7 Medical Ward 6 50

6 2COS

9 Medical ex 20

3 1

5 CD Ward 50

4 6 8

10 Medical ICU 7

7 1 Respiratory ICU ; 4 : 1 6 Acute Stroke Unit 6 : 5 ! Surgery Ward

9 30 . 3 3 nee 1 7 Surgical ICU 6

4 | OB Ward | 100 3 12 5 9 LRDR 5 | 1 3 5 7 2 20 3 1COS 6 3 Orthopedic 2 Ward 30

i 3 2 COS ; 5 Subspecialty

1 28

1 3COS 1 3 Pediatrics 4 +e : 4 4COS F 6 Pediatric ICU 5 7 _ 1 4 3 COS Neonatal ICU 6 30

6 7COS 4 4 Newborn Clinic 1COS Operating 3 Roort 7 1 4 13 5COS 5 5 Post Anesthesia 5 2 5 1 COS

Pavilion South

2 6 5 3 4 Hemodialysis 2 11

8 1COS

2 ENT-Optha 1 Ward 30

I | 3.COS ; ‘i Out-Patient 2 Department . 1 6 5 COS | 5

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324 APPENDIX K DAILY EVERY SHIFT WORK ASSIGNMENT Date and Shift Name of Staff Name of Patient Activities Se Meal July 8, 2019 / Juan Dela Cruz Patient A, B, C, D, E, F, Morning care Break 11:30- 6-2 etc., Medication 12:00pm Administration Carrying out of doctor’s order Doing special nursing procedure Etc.,

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325 APPENDIX L PROPOSED JOB DESCRIPTION OF NURSING PERSONNEL JOB TITLE : NURSE VII (Chief Nurse) POSITION CLARIFICATION : Second Level SALARY GRADE 2 24 KEY ORGANIZATIONAL RELATIONSHI ACCOUNTABLE : Chief of Hospital, Medical Center Chief DIRECTLY SUPERVISES : Nursing Staff JOB SUMMARY : Plans, Organizes, Directs and Controls all the activities of the Nursing Service COMPETENCY MODEL A. CORE : Organizational Commitment Integrity Quality Service Teamwork Stewardship of Resources Attention to Communication Self-Development B. FUNCTIONAL COMPETENCY PROFILE : Knowledge/Skills Behavior Motivation e Leadership end Management | « — J.eading Through Vision Job has opportunities for: e Public Health and Values e = High-Involvement Member e Health Policies e Managing Change e Challenging Work e Research Development e Managing Performance e Achievement e Monitoring and Evaluation e Building a Successful Team e Occupational Hazards and e Building Partnerships Safety Standard Practices e Building Trust e Computer Software e Planning and Organizing Application e Strategic Decision Making e Work Standards KEY RESULT AREAS e Policies, Guidelines, Standards and Protocols Development e Technical Assistance e Staffing plan e Networking e Performance Management e Data and Report Collection e Monitoring and Evaluation e Supervision e Collaboration and Teamwork

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326 FUNCTIONS AND ALLOCATION Functions Time Allocation services. care. personnel. equipment. e Plans, organizes, and supervises the Nursing Service in order to provide quality nursing care to patients. e Collaborates all activities of Nursing Service Department with other e Monitors and evaluates nursing personnel and activities, and recommends improvements to ensure that standards are met. e Formulate and recommends policies for the improvement of patient e Conducts meeting and services programs as a venue to discuss issues, updates in new technologies, and other matters for Nursing Service personnel; participate in meetings as representative of Nursing Service e Participates in the preparation of the Budget Proposal specifically in the area of Nursing Service. e Screens applicants for the nursing service. Prepares and submits nursing service reports are required. e Approves procurement plan to ensure complete hospital supplies and e Coordinates with the Medical Center Chief in developing programs, policies, budget, and other plans for these needs of the nursing service and the improvement of patient care. e __ Performs other related functions as may be assigned. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in Nursing 48 hours of supervisory Two (2) years RA 1080 /management learning and | experience in general development intervention | nursing administration undertaken within the last | and five(5) years Five (5) years of experience in a supervisory or managerial position in nursing WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/Tools e Hospital Based e Other DOH units e Computer e Exposed to health e Other Hospitals/ Agencies |e Fax Machine hazards/accidents e Clients e Photocopier e Telephone

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JOB TITLE POSITION CLARIFICATION SALARY GRADE KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE 327 NURSE VI (Clinical Areas) Second Level 22 Chief Nurse Nurse Supervisors Ensures the delivery of nursing care to all clinical nursing unit. Assist the Chief Nurse in designing and formulating development of policies, guidelines, standards and protocols technical assistance; provides technical supervision of staff; and conducts monitoring and evaluation Organizational Commitment Integrity Quality Service Teamwork Stewardship of Resources Attention to Communication Self-Development B. FUNCTIONAL COMPETENCY PROFILE e Nursing Care e Nursing Supervision e Public Health Behavior Motivation Leading Through Vision and Values Managing Change Job has opportunities for: e High-Involvement Member e Challenging Work e Achievement e Health Policies e Managing Performance e Research Development e Building a Successful Team e Monitoring and Evaluation e Building Partnerships e Occupational Hazards and e Building Trust Safety Standard Practices e Planning and Organizing e¢ Computer Software e Strategic Decision Making Application e Works Standards KEY RESULT AREAS e Policies, Guidelines, Standards and Protocols Development Technical Assistance Staffing plan Networking Supervision Performance Management Data and Report Collection Monitoring and Evaluation

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328 FUNCTIONS AND ALLOCATION Functions Time Allocation nursing service nursing policies. supervisors. of surgery done. performance rating e _ Assists the Chief Nurse in the planning of over all activities of the e __ Assists in the formulation, revision and implementation of hospital and e Assists in the budget preparation for equipment, supplies, physical facilities and personnel. ° Makes general rounds to all clinical wards noting down the needs and problems of patient, personnel and unit as a whole. e Acts on clinical ward issues and concerns in collaboration with nurse e Checks and review a 24 hour report on the actual total number of patients’ admissions, discharges, deaths, number treated, and number e Reviews and analyzes the data prepared for the required reports (daily, weekly, monthly, semi-annual and annual) e __ Assists in maintaining discipline of nursing personnel e Assists in the preparation and evaluation of clinical ward personnel e __ Assists in performing CQI activities in the hospital e Assume functions of the Chief Nurse as delegated by the Medical Center Chief II in the absence of the Chief Nurse. QUALIFICATION STANDARDS

Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in Nursing 40 hours of supervisory 5 years of experience in RA 1080 or its equivalent /management learning and | a supervisory or development intervention | managerial position in nursing WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/Tools e Hospital Based e Other DOH units e Computer e Exposed to health e Other Hospitals/ Agencies | ¢ Fax Machine hazards/accidents e = Clients e Photocopier e Telephone

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JOB TITLE POSITION CLARIFICATION SALARY GRADE KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE B. 329 NURSE VI (SPECIALIZED AREAS) Second Level 22 Chief Nurse Nurse Supervisors Ensures the delivery of nursing care to all specialized nursing unit. Assist the Chief Nurse in designing and formulating development of policies, guidelines, standards and protocols technical assistance; provides technical supervision of staff; and conducts monitoring and evaluation Organizational Commitment Integrity Quality Service Teamwork Stewardship of Resources Attention to Communication Self-Development FUNCTIONAL COMPETENCY PROFILE: Knowledge/Skills Behavior ~~ Nursing Care Supervision Public Health Leading Through Vision and Values Managing Change | Job has opportunities for: e High-Involvement Member e Challenging Work e Achievement Motivation e Health Policies e Managing Performance e Research Development e Building a Successful Team e Monitoring and Evaluation e Building Partnerships e Occupational Hazards and e Building Trust Safety Standard Practices e Planning and Organizing e Computer Software e Strategic Decision Making Application e Works Standards KEY RESULT AREAS Policies, Guidelines, Standards and Protocols Development Technical Assistance Staffing plan Networking Supervision Performance Management Data and Report Collection Monitoring and Evaluation

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FUNCTIONS AND ALLOCATION Functions Time Allocation Assists the Chief Nurse in the planning of over all activities of the specialized area in nursing service Assists in the formulation, revision and implementation of hospital and nursing policies. Assists in the budget preparation for equipment, supplies, physical facilities and personnel. Makes general rounds to all specialized units (ICU’s, ER, OPD, OB complex) noting down the needs and problems of patient, personnel and unit as a whole. Acts on issues and concerns in the specialized units in collaboration with nurse supervisors Checks and review a 24 hour report on the actual total number of patients’ admissions, discharges, deaths, number treated, and number of surgery done. Assists in screening applicants for the specialized areas. Assists in budget preparation in the specialized areas. Reviews and analyzes the data prepared for required reports (daily, weekly, monthly, semi-annual and annual) Assists in maintaining discipline of nursing personnel. Assists in the preparation and evaluation of personnel performance rating in the specialized areas. Assists in performing CQI activities in the hospital QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in Nursing | 40 hours of supervisory 5 years of experience in RA 1080 or its equivalent /management learning and | a supervisory or development intervention | managerial position in 6 months critical care nursing nursing 3 years critical care nursing WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT: Work Condition Contacts Equipment/Tools e Hospital Based e Other DOH units e Computer e Exposed to health e Other Hospitals/ Agencies | e Fax Machine hazards/accidents e Clients e Photocopier e Telephone

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JOB TITLE POSITION CLARIFICATION SALARY GRADE KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE 33] NURSE VI (Assistant Chief Nurse Education, Training & Research) Second Level 22 Nurse VII Education, Training & Research Staff, Nurse Supervisors Clinical Instructors and other Nursing Staff Manages learning and development of nurses, other nursing personnel, and affiliates through planning, implementing, monitoring and training activities related to patient care. Initiates research activities Organizational Commitment Integrity Quality Service Collaboration &Teamwork Stewardship of Resources Attention to Communication Self-Development B. FUNCTIONAL COMPETENCY PROFILE Knowledge’Skills Behavior Motivation Training and Education Methods Basic life Support and OR Techniques Nursing Operation and Administration Use of Medical Equipment and Instruments Occupational Hazards and Safety Standard Practices Computer Software Applications Quality Management Technical Writing Teaching Skills Research Managing Performance Building a Successful Team Building Strategic Working Relationships Building Trust Planning and Organizing Decision Making Work Standards Job has opportunities for: e High Responsibility/ Accountability e Achievement e Challenging Work KEY RESULT AREAS Performance Management Training Report Learning and Development Interventions Programs Monitoring and Evaluation

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332 FUNCTIONS AND ALLOCATION Functions Time Allocation Identifies / assesses training needs of Nursing Service Personnel. Design training programs based on the training needs assessment result. Develops plans and determines resources needed for orientation, training and affiliation programs of nursing personnel, student affiliates. Implement the training plans. Evaluates the outcome of the learning and development intervention conducted. Prepares and updates database of trainings / seminars attended by each Nursing Service Personnel. Organizes and implements affiliation and training programs through screening, teaching, mentoring and other training methods. Collaborates with nurses, clinical instructors, training program coordinators and other health personnel in the implementation of training. Conducts/facilitates research studies to improve the training programs. Monitors pre and post training activities such as preparation of manuals, evaluation reports, and contracts and billing documentation. Orients clinical instructors, students’ affiliates and new employees on related information in the Nursing Service. Ensures that the clinical area assignment of all personnel is based on 14 nursing competencies (CMO 15 s.2017) and trainings acquired. Makes general rounds to all clinical wards and specialized units noting down the training needs of the nursing personnel. Acts on training issues and concerns in the clinical wards and specialized units in collal. oration with nurse supervisors. Reviews & analyze data in the prepared required reports (daily. weekly, monthly, semi-annual and annual). Assists in performing CQI activities in the hospital. Performs other related functions as may be assigned. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of supervisory | 5 years of relevant RA 1080 Nursing /management learning | experience in and development intervention supervisory or management positions 2 years of which as Clinical instructor

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WORK CONDITIONS, CONTACT TOOLS, AND EQUIPMENT 333 Work Condition Contacts Equipment/Tools e Hospital Based e Other LGU Units e Computer e Exposed to health e Clients e A/V equipment hazards/accidents e Academe e Fax machine e Other Hospitals e Telephone e =Calculator e Basic medical equipment

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334 JOB TITLE POSITION CLARIFICATION SALARY GRADE NURSE V (INFECTION CONTROL NURSE) Second Level 20 KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE Nurse VII Nursing Personnel Formulates nursing service policies and standards, and supervises and implements nursing care programs in order to ensure proper patient care related to infection prevention and control. Client Focus Work Standards Integrity Collaboration B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation e Nursing Law, Administration e Adherence to high ethical Job has opportunities for: and Operations standards e Quality Assurance e Role Model e High Responsibility/ ¢ Methods of Research e Emotionally stable | Accountability e Policy and Standards e Professionalism e Challenging Work Development Public Health e Communication e Achievement Surveillance and Infection and e Planning and Organizing Prevention and Control e Decision Making Competence © Adaptability e Patient Assessment Technical Assessment e Occupational Hazards and Safety Standard Practices Training and Development Methods Research oriented Management function Competence in oral and written communication Leadership skills Decision making Motivation Negotiation Skill Computer literate

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KEY RESULT AREAS Nursing and Patient Care Infection Control Procedure Quality Assurance on Infection , Prevention and Control FUNCTIONS AND ALLOCATION Policy, Guidelines, Standards Development on Infection Control Performance Management focused on Infection ,Prevention and Control Coordination and Collaboration skills pertaining to Infection, Prevention and Control 335 Functions Time Allocation e Participates in applying epidemiologic principles and statistical methods, including risk stratification, to identify target population at risk of infection. e Participates in analyzing trends and risk factors, design and evaluate prevention and control strategies. e Acts as coordinator to all hospital staff related to infection control. e Conduct surveillance using Infection Control Committee for criteria. e Document and investigate hospital acquired infections through review of admission diagnosis, microbiology culture results, isolation orders, patients’ records, consultation requests, post- discharge surveillance. e Assesses environmental health and participate in environmental sampling according to the standards of Infection Control. e Participates in investigations of unusual hospital infection outbreaks utilizing the microbiology laboratory, consultation with Infectious Disease Doctors, public health departments and when necessary in consultation with the Department of Health. i Participates in sharp injuri igation and prevention activities | e Report the findings of investigations to appropriate authorities in accordance with the Infection Control Policy. e Participates in clinical audit programs and provide relevant feedback audit results to area concerned and nursing management team. e Ensures that audits carried out conform to criteria set for infection control and best practice. e Monitors staff in in collaboration with the Employees Health Services to prevent hospital related infection among hospital staff. e Serves as preceptor in nursing training program related to prevention and control of infection in the hospital. e Identifies opportunities for clinical audit and research within the field of communicable disease surveillance and infection prevention and management. e Supervises and advise on isolation precautions. e Work with the Hospital Infection Control team to identify, investigate outbreak of infections. e Participates in teaching of hospital staff on matters related to infection control measures. e Conducts research studies relevant to infection control or participated in research initiatives planned by Infection Control Committee. e Performs other functions as may be assigned. e Conducts surveillance of notifiable disease included in the Philippine Integrated Disease Surveillance and Response (PIDSR). ries invest

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336 Functions Time Allocation PIDSR software. Reports to DOH RESU notifiable disease (Category I immediately notifiable within 24 hours Category II weekly) thru encoding in Facilitates collection of specimen and transport to RITM. Follow-up laboratory results from RITM. QUALITY STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of training in 5 years clinical RA 1080 Nursing Infection Control experience 2 years supervisory experience WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/ Tools e Hospital Based Other LGU Units e Computer e Exposed to health DOH units e Telephone hazards/accidents GOs and NGOs Clients Other Stakeholders

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JOB TITLE POSITION CLARIFICATION SALARY GRADE 337 NURSE V (PATIENT SAFETY NURSE) Second Level 20 KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE Nurse VII Nursing Personnel Formulates nursing service policies and standards, and supervises and implements nursing care programs in order to ensure proper patient safety. Client Focus Work Standards Integrity Collaboration Initiating Service B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation e Advance knowledge of Patient | Working Relationships Job has opportunities for: Safety e = Quality Improvement on Patient Safety e Research on Patient Safety e Policy and Standards Development on Patient Safety e Patient Assessment e Occupational Hazards and Safety Standard Practices Training e Competence in oral and written communication Leadership skills Decision making Motivation Negotiation Skill Computer literate eoeee @ e Building Trust e Communication e Planning e Decision Making e Adaptability e Adherence to ethical standards e Role model e Emotionally Stable Emotional e Professionalism e Responsibility e Accountability ¢« Challenging Work e¢ Achievement KEY RESULT AREAS Coordination Nursing and Patient Care Procedure Quality Assurance of Nursing Service Policy, Guidelines, Standards Development Technical Consultation Performance Management

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338 FUNCTIONS AND ALLOCATION Functions Time Allocation e Oversees development of policies and monitoring procedure to document compliance with the professional standard of nursing practice on patient safety. e Conducts quarterly surveys intended to assess the following: o Organization’s culture of patient’s safety including willingness to report error. o Effectiveness of Nursing Patient Safety Program (NPSP) and identify priorities for the program. o Opportunities for improving Patient Safety in the hospital. e Review, analyze and act upon aggregated findings of patient safety surveys and refer to appropriate body / committee. e Performs adverse event detection, analysis and prevention of patient safety related events. e Defines mechanism for providing psychological support to staff who have been involved in the adverse event. e Engages leadership by implementing visibility and sensitivity program of patient safety awareness. © Designs educational materials on patient safety for nursing service personnel, patients and watchers. e Participates actively in research related to patient safety program. e Prepares an annual Nursing Patient Safety Plan. e Performs accurate documentation in support to the structure, process and evidence of effectiveness of the Nursing Patient Safety Program ( NPSP) e Integrate NPSP into the organization’s strategic and organizational plans. e Submits Patient Safety reports to the office of the Chief Nurse to be endorsed to Patient Safety Officer. e Performs other functions as may be assigned. employee’s QUALITY STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of training in 5 years clinical RA 1080 Nursing Patient Safety experience 2 years supervisory or managerial position WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/ Tools e Hospital Based e Other LGU Units e Computer e Exposed to health e DOH units e Telephone hazards/accidents e GOs and NGOs e Clients e Other Stakeholders

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JOB TITLE : NURSE V (DEPARTMENT HEAD) POSITION CLARIFICATION : Second Level SALARY GRADE : 20 KEY ORGANIZATIONAL RELATIONSHIP 339 ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY : Formulates nursing service policies and standards, and supervises and implements nursing care programs in order to ensure proper patient care. COMPETENCY MODEL A. CORE : Client Focus Work Standards Integrity Collaboration Initiating Service B. FUNCTIONAL COMPETENCY PROFILE: Knowledge/Skills Behavior Motivation e Research oriented Working Relationships e Behavior skills e Management function e Adherence to ethical standards e Competence in written and e Building Trust © Role Model oral communication e Communication e Emotionally stable e Leadership skills e Planning e Professionalism e Decision making |e Decision Making e Negotiation skills e Adaptability e Motivation e Adherence to ethical standards e Computer literate e Role model e Emotionally Stable Emotional e Professionalism KEY RESULT AREAS Nursing and Patient Care Procedure Quality Assurance of Nursing Service Policy, Guidelines, Standards Development Technical Consultation Performance Management Coordination eoeee ee FUNCTIONS AND ALLOCATION Functions Time Allocation e Acts as a prime mover of continuous quality improvement initiatives and ensures the maintenance of acceptable nursing standards. e Responsible for all the nursing units and their environment, people, materials, equipment and other resources for excellent operations. e Conducts regular meetings with Nurse IV, III, II and other nursing personnel related to CQI of their clinical areas.

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340 Functions Time Allocation e Conducts learning development and interventions to increase competence of nursing staff. e Coordinates with other department heads and sections of this hospital with consultation and approval of the Nursing Service office. e Coordinates closely with the chief residents and consultants to address matters affecting all department units.. e Conducts purposive rounds to ensure that the standards of nursing practice are upheld at all times. QUALITY STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of relevant 5 years clinical RA 1080 Nursing supervisory /management | experience and 2 years of learning and development | which ina supervisory/ intervention, quality managerial position management WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/ Tools e Hospital Based e Other LGU Units e Computer e Exposed to health e DOH units e Telephone hazard: ‘accidents e Clients e GOs and NGOs e Other Stakeholders

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JOB TITLE POSITION CLARIFICATION SALARY GRADE 341 NURSE V (OR Supervisor) Second Level 19 KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE Nurse VII Nurse IV, Nurse III (OR) Supervises nursing activities in the Operating Room to ensure the quality and safe pre, intra and post-operative patient care. Organizational Commitment Integrity Quality Service Teamwork Stewardship of Resources Attention to Communication Self-Development B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation e = Clinical Nurses «Nursing | aw Operations e Patient Assessment e Technical Writing e OR Techniques and Management financial management e Computer Literate e Nursing Administration and e Medical Equipment Functions e Knowledge of business and e Occupational Hazards and Safety Standard Practices Managing Performance Job has opportunities for: Building a Successful Team Building Strategic Working e High Responsibility Relationships Accountability Building Trust e Achievement Planning and Organizing e Challenging Work Decision Making Work Standards KEY RESULT AREAS e Training and Development Programs e Monitoring and Evaluation e Performance Management

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342 FUNCTIONS AND ALLOCATION Functions Time Allocation Plans and supervises nursing related activities in the Operating Room. Coordinates administrative duties to ensure proper function of staff. Coordinates with other departments regarding patient needs. Coordinates with Central Supply for the requisition of supplies and MMS for the equipment. Monitors and evaluates staff performance based on nursing standards in the delivery of quality nursing care. Prepares and ensure safekeeping of OR records and reports. Determines needs of staff related to professional growth and development, and participates in the orientation and training of new staff, trainees, and student affiliates. Participates in Nursing Audits on patient care, charts and other nursing quality records quarterly. Coordinates with housekeeping and janitorial services for maintenance of cleanliness and orderliness of the unit. Performs other related functions as may be assigned. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of training in| 3years supervisory RA 1080 Nursing Surgical Instruments experience in the Management. | Operating Room Disinfection and Sterilization WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/Tools e Hospital Based e Other DOH Units e Computer e Exposed to health e LGUs/NGOs e =A/V equipment hazards/accidents e Clients e Fax machine e Other Hospitals e Telephone e Calculator e Basic medical equipment

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JOB TITLE POSITION CLARIFICATION SALARY GRADE KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL A. CORE 343 NURSE V (OB Complex Supervisor) Second Level 19 Nurse VII Nursing Personnel Supervises nursing activities in the Delivery Room to ensure provision of quality and safe patient care to Obstetric/Gynecologic and Newborn. Organizational Commitment Integrity Quality Service Teamwork Stewardship of Resources Attention to Communication Self-Development FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation Clinical Nurses Nursing Law Nursing Administration and Operations Patient Assessment Technical Writing Medical Equipment Functions OR Techniques and Management Knowledge of business and financial management Occupational Hazards and Safety Standard Practices Computer Literate eeee Managing Performance Job has opportunities for: 3uilding a Successful Team Building Strategic Working | ¢ High Responsibility Relationships Accountability Building Trust e Achievement Planning and Organizing e Challenging Work Decision Making Work Standards KEY RESULT AREAS e Training and Development Programs e Monitoring and Evaluation e Performance Management

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344 FUNCTIONS AND ALLOCATION Functions Time Allocation Plans and supervises nursing related activities in the OB Complex. Coordinates administrative duties to ensure proper function of staff. Coordinates with other departments regarding patient needs. Coordinates with Central Supply for the requisition of supplies and MMS for the equipment. e Monitors and evaluates staff performance based on nursing standards in the delivery of quality nursing care. e Prepares and ensure safekeeping of OB records and reports. e Determines needs of staff related to professional growth and development, and participates in the orientation and training of new staff, trainees, and student affiliates. e Participates in Nursing Audits on patient care, charts and other nursing quality records quarterly. e Performs other related functions as may be assigned. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of supervisory | 3 years supervisory RA 1080 Nursing training experience in OB 18 hours Lactation Complex | Management | | WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT Work Condition Contacts Equipment/Tools e Hospital Based e Other DOH Units e Computer e Exposed to health e LGUs/NGOs e A/V equipment hazards/accidents e Clients e Fax machine e Other Hospitals e Telephone e Calculator e Basic medical equipment

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345 JOB TITLE : NURSE III (Ward Supervisor) POSITION CLARIFICATION : Second Level SALARY GRADE ¢ 17 KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE : Nurse VII (Chief Nurse) DIRECTLY SUPERVISES : Nursing Personnel JOB SUMMARY : Supervises the Nursing care service unit/s through mentoring and monitoring of work performance of nursing staff; performs clinical functions; and participates in the development of policies, rules, and regulations. COMPETENCY MODEL A. CORE : Client Focus Collaboration Initiating Service Integrity Work Standards Change Management B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation e Patient Care e Delegation Job has opportunities for: e Basic Medical Procedures |e Supervision e Usage of Medical Equipment | « Building Strategic Working ¢ — Relationship Building and Instruments Relationships e Achievement e Drug Regulations e =Building Trust e Challenging Work e Training and Teaching e Communication Methods e Teamwork e IV Therapy e Information Monitoring e Performance Management e Planning and Organizing e Occupational Hazards and e Problem solving and Decision Safety Standard Practices Making e Continuous Learning e Adaptability e Adherence to ethical standards KEY RESULT AREAS: e Patient Care Service e Training, Education, and Development e Performance Management e Policy Development e Equipment, Supplies and Facility Maintenance e Report Preparation

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346 FUNCTIONS AND ALLOCATION Functions Time Allocation Plans and supervises nursing related activities. Assist in the development of plans, policies, procedures and standards related to the delivery of nursing services. Monitors performance of nurses and other nursing personnel in the unit. Identifies training needs of nursing staff and personnel in the unit. Prepares monthly nursing and health program reports. Coordinates with other departments relative to patient care. Plans and implement patient safety programs in the unit. Ensures adequate medical supplies and functional equipment in the area. Ensures adherence to established policies and procedures in the unit. Evaluate the performance of nursing personnel in the unit. Plans and ensures adequate manpower in the unit. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Master of Arts in 40 hours of relevant 3years experience as Nursing training Senior Nurse RA 1080 WORK CONDITIONS. CONTACT TOOLS AND EQUIPMENT: Work Condition Contacts Equipment/Tools Other LGU units DOH units GOs and NGOs Clients Other Stakeholders Academe Professional Organization Hospital Based Exposed to health hazards/accidents Computer Fax machine A/V equipment Photocopier Telephone Calculator Medical Devices

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JOB TITLE : NURSE II (Senior Nurse) POSITION CLARIFICATION : Second Level SALARY GRADE ¢ JS KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE DIRECTLY SUPERVISES JOB SUMMARY COMPETENCY MODEL: A. CORE Nurse VII (Chief Nurse) Nursing Personnel Provides direct nursing care through mentoring and monitoring nursing staff and students; performs regular staff functions when necessary. Acts as charge nurse Client Focus Collaboration Initiating Service Integrity Work Standards B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Patient Care Basic Medical Procedures Use of Medical Equipment and Instruments Drug and Medicine Regulations Training and Teaching Methods IV Therapy Performance Management Occupational Hazards and Safety Standard Practices Research Behavior Motivation Building Trust Job has opportunities’ for: Building Client Loyalty Communication e Relationship Building Teamwork ¢ Challenging Work Planning and Organizing e = Achievement Decision Making Continuous Learning Adaptability KEY RESULT AREAS Report Preparation Patient Care Service Training, Education, and Development Performance Management Equipment, Supplies and Facility Maintenance Quality Management

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348 FUNCTIONS AND ALLOCATION Functions Time Allocation Provides guidance and support for ward staff. o Using coaching and mentoring technique with individual staff © Promoting a work environment conducive to harmonious work relationship and high staff morale Ensure care is provided to patient in accordance with the appropriate professional and hospital standards. o Ensuring that all patients contacts are documented, treatment, plans implemented and evaluated in timely manner consistent with the evidence based practice Monitor and evaluate performance of nursing staff and non-professional staff in providing patient care. Provides a safe environment to patient’s visitors and other staff. o Understanding and promoting emergency procedures such as fire response and evacuation o Observing and promoting all professional graduates for practice regarding infection control Promotes, monitor and participate in all quality improvement activities. Maximize the education and development of staff and self. ° Participate in a performance appraisal and identifying personal goals and strategies Manages all treatment and care related resources in effective and cost efficient manner. Performs other related functions: o Performs direct nursing procedures which includes bedside nursing, peri-operative nursing care, admission and discharge duties Administers medication and notes reaction Maintains records reflecting patient’s condition, on medication and treatment © Coordinates with other section in the hospital regarding client care o Assist in the education and rehabilitation of patient and their families related to physical and mental health QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Bachelor of Science in | 24 hours of relevant 1 year of relevant RA 1080 Nursing with 15 MAN training clinical experience Units WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT: Work Condition Contacts Equipment/Tools Hospital Based e Other LGU, DOH units e Computer Field work as needed e GOs and NGOs e Fax machine Exposed to health e —Clients/Stakeholders e A/V equipment hazards/accidents e Academe e Photocopier e Professional Organizations e Telephone e Calculator

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349 JOB TITLE : NURSE I (Staff Nurse) POSITION CLARIFICATION : Second Level SALARY GRADE : 11 KEY ORGANIZATIONAL RELATIONSHIP ACCOUNTABLE : Nurse VII (Chief Nurse) DIRECTLY SUPERVISES : Nursing attendant JOB SUMMARY : Performs direct nursing care services and assist physicians in diagnostic and therapeutic procedures in order to provide proper patient care. COMPETENCY MODEL A. CORE : Client Focus Collaboration Initiating Service Integrity Work Standards B. FUNCTIONAL COMPETENCY PROFILE Knowledge/Skills Behavior Motivation e Nursing Degree and clinical e Building Trust Job has opportunities for: Nursing e Building Client Loyalty e = Nursing Law e Communication e Relationship Building e Nursing Patient Care e Teamwork e Challenging Work Procedures }« Planning and Organizing s Achievement e Patient Assessment e Decision Making e Occupational Hazards and e Continuous Learning Safety Standard Practices e Adaptability

e JV Therapy KEY RESULT AREAS e Nursing Service and Patient Care e Health Information ¢ Medication and Treatment Administration e Patient and Health Education e Patient Record Maintenance © Coordination FUNCTIONS AND ALLOCATION: Functions Time Allocation e Utilizes assessment skills and techniques to determine patient’s problems and needs. e Develops and documents the plan of care based on patient’s condition /needs. Carries out the plan of care according to priority. Provides safe and comprehensive care according to standards.

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350 Functions Time Allocation Performs direct nursing care procedures which include bedside nursing, hygiene, pre and post-operative nursing care, admission, and discharge duties. Monitors, records, and reports patient’s symptoms, condition, and progress of treatment and therapy. Administers medications following the golden rules. Prepares patients for, and assists physicians with diagnostic and therapeutic procedures. Assists in the education and rehabilitation of patients and their families related to physical and mental health. Conducts/ participates in research studies. Maintains the confidentiality of patient’s data. Coordinates with other sections in the hospital regarding patient care. Performs other related functions. QUALIFICATION STANDARDS Minimum Requirement of the Position Education Training Experience Eligibility Bachelor of Science in None None RA 1080 Nursing WORK CONDITIONS, CONTACT TOOLS AND EQUIPMENT

| Work Condition |

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Contacts | Equipment ’Too!: e Hospital Based e Other LGU units e Computer e Field work as needed e Clients e Visual Aids e Exposed to health e Nursing Interns e Mobile Phone hazards/accidents e Telephone e Fax machine

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351 APPENDIX M REPUBLIC ACT NO. 10968 AN ACT INSTITUTIONALIZING THE PHILIPPINE QUALIFICATIONS FRAMEWORK (PQF) H. No. 6872 S. No, 1456 Republic of the Philippines Congress nf the Ubilippines Motes Manila Senetteonth Congress Second Regular Session Begun and held in Metro Manila, on Monday, the twenty-fourth day of July, two thousand seventeen | RepuBuic Act No. 10968 | AN ACT INSTITUTIONALIZING THE -PHILIPPINE QUALIFICATIONS FRAMEWORK (QE), ESTABLISHING THE PQF-NATIONAL COORDINATING COUNCIL (NCC) AND APPROPRIATING FUNDS THEREFOR Be it enacted by the Senate anid House of Representatives of the Philippines in Congress assembled: SECTION 1. Short Title. ~ This Act shall be known as the “PQF Act”. Sec. 2. Declaration of Policy. - Pursuant to the constitutional guarantee for the State to promote the right of all citizens to quality and accessible education at all levels, the State shall establish, maintain, and support.a complete, adequate and integrated system of education relevant to the needs of the people and society.

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352 In recognition of the important role of education and training in national development, it is hereby declared the policy of the State to institutionalize the Philippine Qualifications Framework (PQF) to encourage lifelong learning of individuals, provide employees specific training standards and qualifications aligned with industry standards, ensure that training and educational institutions comply with specific standards and axe accountable for achieving corresponding léarning outcomes, and provide govérnment with a common taxonomy and qualifications typology as bases for recognizing education and training programs as well as the qualifications formally awarded and their equivalents.

SEC. 3. Definition of Terms. — As used in this Act: (@) Basic Education refers to that part of the educational system intended to meet basic learning needs and provides the foundation on which subsequent learning can be based. Jt encompasses kindergarten, elementary and secondary education as well-as alternative learning systems. for out-of-school ‘youth and those with special -n : (b) Higher Education refers to post-secondary education offered uéually by universities, colleges, academics, or professional/(echnical institutions with programs leading to the post-baccalaureate © Qualification vefers to a formal certification that a person has successfully achieved. specific learning outcomes relevant 4o the identified academic, industry or community requirements. A qualification confers official recognition of yalue in the labor market and in further education and training; @ Technical Vocational Education and Training refers to the education involving the atudy of technology-related sciences, in addition to general education, as well as the acquisition of practical skills relating to occupations in various sectors 6f economic life and social life, and which _

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comprises formal (organized programs as part of the school system) and non-formal (organized classes outside the school system) approaches; and ©) Trifocalized Education and Training refers to the shared administration of the education system by the three (3) agencies responsible for each education level: the Department of Education (DepED) for basic education; the Technical Education and Skille Development Authority (TESDA) for technical-vocational education and training; and the Commission on Higher Education (CHED) for higher education. Sec. 4, Philippine Qualifications Framework (PQF). ~ A PQF shall be established which shall describe the levels of educational qualifications and sets the standards for qualification outcomes, It is a quality assured national system for the development, recognition and award of qualifications based on standards of knowledge, skills and values acquired in different ways and methods by learners and workers of the country. The PQF shall have the following objectives ational standards and levels of ¢ of education; (a) To learning oute {b) To support the development and maintenance of pathways and equivalencies thai enable access to qualifications and to assist individuals to move easily and readily between the different education and training sectors and between these sectors and the labor market; and () To align domestic qualification standards with the international qualifications framework thereby enhancing recognition of the value and comparability of Philippine qualifications and supporting the mobility of Filipino students and workers. 353

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354 Sec. 5. Philippine Qualifications Framework-National Coordinating Council (PQF-NCC). ~ In order to harmonize and promote a seamless education and training system, the PQF-NCC is hereby established. It shall be composed of the following: @) The Secretary, DepED, as Chairperson; (b) The Secretary, Department of Labor and Employment (DOLE), as member; () The Chairperson, CHED, as member; @ ‘The Director General, TESDA, as member; @ The Chairperson, Professional Regulation Commission (PRC), as member; ® One (1) representative of the economic sector, as member; and fg) One (1) representative of the industry sector, The PQF-NCC shall be chaired by the DepED Secretary and shall have the following powers and fumetions: () To harmonize qualification levels across basic, technical-vocational and higher education; @) To align education standards and learning outcomes with the level descriptors contained in the PQF; 43) To promote the PQF and its elements, including the principles, key features, definitions or terminologies, structure, and governance arrangements, and provide information and guidelines in the implementation of the PQF;

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a {4) To rationalize the quality assurance mechanisms in Philippine education; (5) Todevelop and recognize pathways and equivalencies: (6) To maintain the national registry of qualifications; (7) To ensure the international alignment of the PQF with the qualification frameworks of other countries or regions; ®) To create technical working groups in support of the development and implementation of the PQF; 9) To represent the country in international fora or negotiations in line with qualifications agreements or arrangements; (10) To review and update the PQF; 11) Te submit to the Office of the President. the Senate of the } au updated rey on the progress and accon relation to the PQF; and (12) To perform such other functions that may be related to the implementation of the PQF, Sec. 6. Establishment of the PQF-NCC Werking Groups, ~ To pursue the implementation of the PQF, working groups shall be established, especially in the areas of qualifications register, quality assurance, pathways and equivalencies, information and guidelines, and international alignment. Each working group shall be chaired by a member-agency as may be designated by the PQF-NCC. 355

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356 SEC. 7. Participation of the Industry Sector. - Industry sector representatives shall be consulted and tapped in the development and implementation of the PQF to ensure the alignment of educational outeomes with industry requirements and add to the value of qualifications within the workplace. Sec, 8. Framework and Level Descripiors. - The PQF ‘shall incorporate the gualifications level descriptors defined in terms of knowledge, skills and values, application, and degree of independence. The PQF-NCC shall make detailed descriptors for each qualification level following the principles of lifelong learning and the récognition of prior learning from previous informal experiences, while incorporating the learning standardz in basic education, competency standards of training regulations, and the policies and standards of higher education academic programs. The PQF-NCC members shall jointly implement national pilot programs to determine their relevance and pacers eed in ae levels of coy tomes The ae shad pre penardine ihe demand for specific qualifieatio g emerging occupations as bases for the prioritization of learning standards development. SEC. 9. Review of Assessment System. — The PRC and the CHED shall review the system of assessment of jearning outcomes and align them with those of the PQF. SEC. 10. Permanent Secretariat, ~ The PQF-NCC Shall organize a permanent technical seeretariat. The Secretariat may contract the services of technical experte and authorities on relevant areas of concern such as equivalencies, accreditation, curriculum development, educational measurement and testing. sat

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357 The PQF-NCC shall determine the structure, composition, staff qualifications and the location of the permanent secretariat. SEC. 11. Identification of Priority Sectors. ~ As a preliminary approach to the implementation of the PQF and to ensure its more focused implementation, the CHED, the TESDA and the DepED, in consultation with the industry, the DOLE, the PRC, the Department of Trade and Industry (DTI), the National Economic and Development Authority (NEDA), the Department of Science and Technology (DOST), and other related agencies, are directed to identify priority sectors and programs for the POF, taking into account labor market realities, SEC. 12. Support from Other Government Agencies. — The DOST, the NEDA, the Department of Budget and Management (DBM), and other related agencies are hereby mandated to extend the necessary support and provide relevant inputs towards the effective implementation of the PQF. , TESDA and DepED. Thereafter. the funds ary for the continuous implementation of this Act in the ensuing years shall he included in the annual General Appropriations Act. SEC. 14. Implementing Rules and Regulations. ~ Within ninety (90) days after the effectivity of this Act, the DepED, CHED, TESDA, DOLE and PRC, in consultation with relevant stakeholders, shall issue the necessary rules and regulations for the effective implementation of this Act. Sec. 15. Separability Clause. — If any part or provision of this Act shall be held unconstitutional or invalid, the other parts or provisions hereof that are not affected, shall continue to be in full force and effect.

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358 SEC. 16. Repealing Clause. Alllaws, rules, regulations, proclamations, executive orders or parts thereof inconsistent with the provisions of this Act are hereby modified or amended accordingly. Sec. 17. Effectivity. ~ This Act shall take effect fifteen (15) days after its publication in the Official Gazette or in a national newspaper of general circulation. Approved, AN: wo N 3 AQUILINO KOKO" L SLUT = PANTALEON D. President of the Senate Speaker of the of Representgti This Act wae passed by the House of Representatives as House Bill No. 6572-on November 21, 2017 and adopted by the Senate as an amendment to Senate Bill No. 1456 on December 13, 2017. F: LUTGARDO B. BARBO hort AR STR4“Se Secretary of the Senate Secretary Gen eral House of Representatives Approved: MIAN 1.6 2070 RODRI ‘OSTERTE President of the Philippines 0

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359 APPENDIX N PROFESSIONAL REGULATORY BOARD OF NURSING RESOLUTION NO. 21 SERIES OF 2017 Y a Republic of the Philippines B Drofessional Wequlation Commission < Manila PROFESSIONAL REGULATORY BOARD OF NURSING Resolution No. 21. Series of 2017 OPERATIONAL GUIDELINES FOR THE IMPLEMENTATION OF RA10912, OTHERWISE KNOWN AS THE “CONTINUING PROFESSIONAL DEVELOPMENT (CPD) ACT OF 2016” FOR NURSING WHEREAS, Section 2 of Article 1 of the Republic Act (RA) No. 9173. otherwise known as the “Philippine Nursing Act of 2002”. provides for the policy of the State to regulate and professionalize the practice of profession, fo wif: “Section 2. Declaration of Policy. — It is hereby declared the policy of the State to assure responsibility for the protection and improvement of the nursing profession by instituting measures that will result in relevant nursing education, humane working conditions, better career prospects and a dignified existence for our nurses. The State hereby guarantees the delivery of quality basic health services through an adequate nursing personnel system throughout the country.”: WHEREAS, under Section 15 of Article {V of Republic Act 10912. otherwise known as the “Continuing Professional Development (CPD) Act of 2016", the Professional Regulatory Boards (Board) are given the authority to prescribe their own requirements or procedures relating to the CPD as may be pertinent and applicable to their respective professions, PROVIDED, that the same does not contravene any of the provisions of RA 10912 and its Implementing Rules and WHEREAS, the nurses have to expand ther knowledge and technica! competencies in light of the complexities of the healthcare needs and demands for better delivery of safe nursing care services, and that in line with meeting the ASEAN Core Competency Standards as well as other international and global standards, there is a need to continuously update themselves in order to meet these challenges. NOW THEREFORE, the Professional Regulatory Board of Nursing (Board) hereby RESOLVED, as it now RESOLVES, to formulate its own Operational Guidelines of the CPD Program in accordance with the provisions of RA 10912 and its implementing Rules and Regulations. as follows: Section 1. Date of Regular Meetings. ~ The CPD Council for Nursing, under the supervision of the Board, is hereby mandated under this Resolution to meet every last Friday of the month for the purpose of evaluating the applications for accreditation as CPD provider, program, self- directed learning, and other modalities for lifelong learning and other CPD-related matters. Section 2. List of Additional Requirements for Accreditation of CPD Provider. — The list of documentary requirements for accreditation of CPD Local and Foreign Providers as provided for in Resolution No. 1032, s. of 2017, shall also include the following, but not limited to: P, PAREDES ST., SAMPALOC, MANILA. PHILIPPINES. 1008 P.O. BOX 2038, MANILA

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360 cope aay Page 2 of 4 PROFESSIONAL REGULATORY BOARD OF NURSING OPERATIONAL GUIDELINES IN THE IMPLEMENTATION OF RA 10912, OTHERWISE KNOWN AS THE “CONTINUING PROFESSIONAL DEVELOPMENT (CPD) ACT OF 2016” FOR NURSING 2.1 Local Provider 2.1.1 Sole Proprietor — Evidences / Capability of the following: a Proof of expertise of the applicant on the program to be offered b. Adequate facilities and equipment for training C. Training Program plan for three (3) years A copy of the Application Form for Accreditation as CPD Provider is hereto attached as Annex “c Section 3. List of additional requirements for accreditation for CPD Program. —The list of documentary requirements for Accreditation of CPD Program as provided for in Resolution No. 1032, Series of 2017, shail also include the following, but not limited to: 3.1 Instructional Design. A copy of the template is hereto attached as Annex “D”; 3.2 Proof of expertise of the faculty (lecturer, facilitator, preceptor) on the program/s offered: and 3.3 Special Temporary Permit (STP) for foreign faculty A copy of the Application Form of Accreditation of CPD Program/s is hereto attached as Annex Section 4. Major Areas of CPD Activities. - The CPD Activities shall be divided into five (5) major areas based on the ASEAN Nursing Core Competencies. The coverage of each major area shall include but not be limited to: Major Area_ Coverage of the Area Ethics and Regulatory | Philippine Nursing Law. Code of Ethics 5 issuances ' Professional Nursing Practice Ecucation and Research Philippine Professional Nursing Practice Standards, Philippine Nursing Roadmap Policy De “Education and Research, Curriculum Development Evidence-Based Practice, Research Agenda based on National Higher Education Research Agenda (NHERA) and National Unified Health Research Agenda (NUHRA) for Nursing Practice, other health research agenda and graduate and Post-graduate Studies/Programs 15 10 “Credit Units Required | i Professional, Personal, Quality Development, and Lifelong Learning Nationa! Nursing Career Progression (Advanced Practice Nursing, Nursing Education, Leadership and Governance) Nursing Informatics, and Continual Quality Improvement 40

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Page 3 of 4 PROFESSIONAL REGULATORY BOARD OF NURSING OPERATIONAL GUIDELINES IN THE IMPLEMENTATION OF RA 10912, OTHERWISE KNOWN AS THE “CONTINUING PROFESSIONAL DEVELOPMENT (CPD) ACT OF 2016” FOR NURSING Section §. In-Service Training Programs. ~ The In-Service Training Programs shail form part of the Continuing Professional Development (CPD) program. The provisions of Board Resolution No. 34, s. of 2015, shall be adopted. However, procedures for accreditation of CPD providers and programs shall be governed by the IRR of RA 10912 and this Operational Guidelines. Section 6. Training Programs for Specialization. — All training programs offered by accredited specialty organizations as requirements for specialization have to be accredited by the CPD Council of Nursing. Accredited specialty organization may be deputized to evaluate the application for specialty programs. Section 7. Additional Activities under Self-Directed and/or Lifelong Learning Track. — The following list of additional activities may also be applied for self-directed and/or other modalities for lifelong learning. Documents to be submitted in support of the application Copy of the peer-reviewed module Activity Credit Units (CU) : Module Development Maximum of twenty (20) Evaluation Tool Copy of the evaluation tool tested Development for Clinical Performance and others for validity and reliability Maximum of twenty (20) _ Policy Development for Leadership and jovernance Track A copy of the approved policy Maximum of ten (10) "Studies for Advanced | Practice Nursing in any | setting Research abstract Maximum of thirty (30) | Socio-civic. cultural. religious and other fields tivities Certification from the sponsoring f organization Maximum of five (5) Current Contract with the foreign employer and Certificate of CPD program attended _ CPD Programs attended by the OFWs in their countries of employment Maximum of 26 per year Section 9. Maximum Creditable Units for Self-Directed and/or other modalities for Lifelong Learning. ~ The maximum creditable units for self-directed and/or other modalities for fifeiong learning not accredited by the CPD Council ts ten (10) per year except for those activities enumerated in Section 7 and under the Academic Track of the Matrix of CPD Activities. Section 10. CPD Provider Completion Report. — The list of documentary requirements for the submission of the Completion Report by the CPD provider as provided for in Resolution No 1032, s. of 2017, is hereby adopted. However. it shall also include the summary of the evaluation of the program offered. A copy of Completion Report is herein attached as Annex °F”. Section 11. Required CPD Credit Units in a Compliance Period. ~ All members of the nursing profession shail be required to comply with forty-five (45) CPD units within a compliance period of three (3) years, the implementation of which shall be gradual as follows: 361

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362 Page 4 of 4 PROFESSIONAL REGULATORY BOARD OF NURSING OPERATIONAL GUIDELINES IN THE IMPLEMENTATION OF RA 10812, OTHERWISE KNOWN AS THE “CONTINUING PROFESSIONAL DEVELOPMENT (CPD) ACT OF 2016” FOR NURSING. Required Number of | Minimum allowed to be earned earof Renewal CPD Credit Units _ per year January ~ December 2017 0 | 0 January - December 2018 15 i 15 January 2019 - onwards 45 45 Section 12. All provisions of PRC Resolution No. 1032, s. of 2017 IRR of RA 10912, known as CPD Act of 2016 shall apply. Section 13. Repealing Clause. — All laws, decrees, executive orders, and other administrative issuances or parts thereof which are inconsistent with the provisions of RA 10912 and this Operational Guidelines are hereby repealed or modified accordingly. Section 14. Effectivity. — This Operational Guidelines of the IRR of RA 10912 shall take effect after fifteen (15) days following its full and complete publication in the Official Gazette or in any newspaper of general circulation in the Philippines. Copy furnished the U.P. Law Center. Done in this 13thday of __ October __ 2017 in Manila. Philippines. Chair tA dead 0 OPLAALLLS eseuee dy CORA A. ANONUEVO. GLORIA 8. ARCOS Member lember FLOKENCE C. CAWAON CARMELITA C. DIVINAGRA Member “ Member Bes F He. UATE OF Atty. LOVELIKA T. BAUTISTA OFFILIA Officer-In-Charge AATE CF Secretary to the Professionai Regulatory Boards APPROVED BY: Ap for P TEOFILO S. PILANDO, JR. Chairman (VACANT) Commissioner YOLANDA D. REYES Commissioner (0-OCH/O--OCI/PRB-NSG/D-LIDD-SPRBD-CPOD! TSPADRIGSAERIMLTBMLMHimeragiapal

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ANNEX “AY Definition of Terms: Bachelor of Science in Nursing (BSN) — refers to the baccalaureate program that provides sound and liberal professional education that equips graduates with competencies for registration and entry-level nursing practice in accordance with the appropriate qualification framework. The BSN program is effectively promulgated under the enabling Policies, Standards, and Guidelines (PSG) prescribed and issued by the Commission on Higher Education (CHED). In-Service Training Program — refers to any program offered by hospitals or health care institutions at no cost to its employed Nurses to enhance and upgrade their clinical competencies, and to address the needs of the hospital or health care institution for efficient, effective and responsive delivery of health care services. In-Service Training shail not be required as precondition for employment. Institutions — refer to any government or privately-led, -owned, or —controlled establishment which pursues and realizes the lofty goals and objectives of providing and managing safe, efficient. effective, and quality health programs, services, and advocacies for health in all levets of the Health Care Delivery System. National Nursing Career Progression Program (NNCPP) — refers to a program undertaken by a nurse to achieve recognition in a specially defined nursing track. National Nursing Core Competency Standards ~ refers to statements of competency for Nursing Practice in the Philippines emphasizing the three roles of nurses: Beginning Nurses’ Role on Client Care, Beginning Nurses’ Role on Management and Leadership. and Beginning Nurses’ Role on Research Competencies for their performance in the key areas of responsibilities, and the types of Clients for nurses, namely: the individual, family, population group, and the community. Nursing Human Health Resource Management System (NHHRMS) - refers to a set of human resource management and development system that will provide the nursing workforce with quality work life characterized by productivity, job security, competen: job-based recruitment and selection, learning and development. and profess 363

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364 ANNEX “B” CONTINUING PROFESSIONAL DEVELOPMENT for THE NURSING PROFESSION: A FRAMEWORK A graduate of the Bachelor of Science in Nursing (BSN) Program, after passing the Nurse Licensure Examination (NLE), is classified as a Level 6 professional {Philippines Qualifications Framework). Learning is a continuous process. it is life-long. In consonance with the Philippine Qualifications Framework (PQF) and the ASEAN Qualifications Reference Framework ({AQR), the Continuing Professional Development Council (CPDC) of the Professional Regulatory Board of Nursing (PRBON) developed a framework to guide service providers in crafting their programs for their stakeholders. The Continuing Professional Development (CPD) programs can be provided through either a combination of formal and/or informal education and self-directed learning, and through professional work experiences. The CPD programs will utilize the Whole-brain Learning System model. This model was developed by Dr. Eduardo Morato, dr. in 2012. Dr. Morato believes that “a person must tap the full faculties of the brain, the heart, and the spirit to be the best he or she can ever be.” To attain personal excellence, he identified seven self-mastery skills that should be learned and developed (Annex “A’). Taking this as a premise for ail CPD programs, the service providers should be guided by the tenet “do more MENTORING rather than lecturing, COACHING rather than telling.” The framework takes into consideration the National Nursing Career Progression Program (PRBON Resolution No. 22, series 2009) for the continuing growth and development of the nurse practitioners. Thus, through the CPD programs, a level 6 nurse generalist can be classified later on, upon credentialing by the PRBON into Level 7 or Level 8 professional in any of the three tracks of 10 Advanced Nursing Practice: 2) Nursing Education; or 3) Leadership and Governance. To implement this framework. an instructional Design Template will be used for al! the programs submitted for accreditation (Annex “D’} WORK EXPERIENCE/S FORMAL

. EDUCATION eS LEARNING Seven Levels of Mastery ay
Accreditation: canaeart: Lesroing ts Learning to Learning to Fee! De .

Learning to Learning to i x Communicate tead Advanced Leadership aasrhing to 5 jursing Be Nursing acation & Practice Governance Figure 1. Continuing Professional Development for the Nursing Profession: A Framework ATHOd ROR Heer aa menqane

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365 ANNEX “C” Professional Regulation Commission APPLICATION FOR ACCREDITATION AS CPD PROVIDER (LOCAL) CPD Council of NURSING | Renewal = Accreditation No. Expiry Date Part i. Personal / Corporate Information Name of Provider: . Classification: individual/Sole Proprietorship QO Firm/Partnership/Corporation ial Government Institution/Agency | Address: Telephone No.: . Fax No. E-mail Address: "Website: — Contact Person: Contact No: | Part ll. Acknowledgment 2 Gs || HEREBY CERTIFY that the above information | SUBSCRIBED AND SWORN to before me this i | written by me are true and correct to the best of my ' day of 20... at | knowledge and belief. {| further authorize PRC and . affiant exhibited to me | other agencies to investigate the authenticity of all the | his/her valid government issued 1D | documents presented. | issued at on ae | Signature Over Printed Name {Notary Public) Position CPD Division: Reviewed by: Atty. MARIA LIZA M. HERNANDEZ : } Division ACTION TAKEN BY THE CPD COUNCIL (3 Approved Accreditation No. [1 Deferred pending compliance _ (2) Disapproved due to Chairperson Member Member i Date.

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366 ANNEX °C” PROCEDURE FOR ACCREDITATION AS CPD PROVIDER (LOCAL) Step 1 | Step 2. i | Step 3. | Step 4. Step 5. download at PRC website (www.pre.gov.ph). for receiving copy) and assessment. Secure Application Form at the Continuing Professional Development (CPD} Division counter or Fill-out Application Form and comply the required documents. Application should be filed in one (1) original signed with the complete requirements with folder and fastener. (Please provide one (1) set Proceed to Continuing Professional Development (CPD) Division processing window for evaluation Pay prescribed fee (in cash, Postal Money Order, Manager's Check. Bank Draft payable to Professional Regulation Commission) of Five Thousand Pesos (P 5,000.00). Submit Application Form with attached supporting documents and a photocopy of official receipt to the Continuing Professional Development (CPD) Division designated window. CHECKLIST OF REQUIREMENTS 1 SUPPORTING DOCUMENTS tod {J Additional Requir [ ] Short brown envelope for the Certificate of Accreditation { ] One set of metered documentary stamps worth Twenty-Five Pesos (P25.00} to be affixed to the individual / Sole Proprietor Résumé must include: relevant Educational background, current employment, profession, principal area of professional work & No. of years in the practice of the regulated profession valid Professional Identification Card Company Profile must include Mission, Vision, Core Values and if any, a list of previous taining activities conducted List and photographs of taining equipment and facilities instructional Design (one} Plan of proposed CPD Activities for three (3) years } DTI Certificate of Registration {authenticated copy} NBi Clearance {original} BIR Certificate of Registration fauthenti i CPD Ae Gener Amended Articles of 1 Firm / Partnership / Corporation | ] Company Profile must include Mission, Vision, Core Values and if any. a list of previous taining activities conducted ] List of Officers with valid Professional 1D Card {if applicable} List and photographs of training equipment and facilities Instructional Design (one) Annual! pian of proposed CPD Activities Appointment paper from the managing partner or Board Resolution of a Corporation authorizing a partner or officer to manage the CPD activities SEC Certificate of Registration and Articles of incerporation or Partnership clive By-laws Renewal i facial ion Sheet for Corporation or Partnership ‘orporation or Partnership and their respective by-laws, if there are changes Government institution/Agency — {| ] Copy of charter or Republic Act establishing the agency { ] Instructional Design fone} ] Annual plan of proposed CPD Activities Office Order from the head of Agency appointing its officer to manage the CPD activities Appointment paper from the managing partner or Board Resolution of a Corporation authorizing a pariner or officer to manage the CPD activities or Office Order from the head of government agency appointing its officer to manage the CPD activities, if there are changes. Notarized Affi ents: tof Undertaking (CPDD-06) . Certificate of Accreditation. (Available at PRC Customer Service and PRC Regional Offices} Note: 45 Representative/s filing application/s for accreditation and claiming the Certificate of Accreditation in behalf of the applicant must present a letter of authorization and valid identification cards of both the authorized signatory and the representative. . The period for processing the application is 60 days. |. If additional requirement/s is/are needed, a period of 15 days is given to submit the same. Failure to comply within the period shail be construed as abandonment of application and the prescribed fee shall be forfeited in favor of the government,

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367 ANNEX “D" Professional Regulation Commission TEMPLATE FOR INSTRUCTIONAL DESIGN FOR CONTINUING PROFESSIONAL DEVELOPEMENT (CPD) PROGRAMS VIL CPD Council of NURSING Name of Institution / Organization Program Title: Program Code: (Each service provider will make its own code) Career Track Contact Hours Intended Audience Prerequisites (Entry competencies for the participants to get the full benefits of the program. This can serve as the baseline data that will be the basis/bases for the assessment [both formative and summative] of the effectiveness of the program offered.) instructional Design Application, i | Formative | Summative + Finding cut how much learning has taken piace | = Leaming outcomes are measured again by | standards What does the demonstration of learning for each

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368 ANNEX “E" Professional Regulation Commission APPLICATION FOR ACCREDITATION OF CPD PROGRAM CPD Council of NURSING [ Part 1. General information | Name of Provider: Accreditation No.:

Expiration Date: © Contact Person: Designation: Contact No.: Date of Application: Proposed Progam; Seminar ‘el SeminarWorkshop [] Residency Training [—] Tours & visits ["] others Title of the Program: Date to be offered: Time / Duration: ‘Place / Venue: No. of times program to be conducted: Course Description: — Objectives: Target Participants / No.: —_ T Registration / Seminar Fee to be collected: Parti, Acknowledgment | HEREBY CEATIFY that the above information written by T SUBSCRIBED AND SWORN to before me this day me are true and correct to the best of my knowledge and | of 20 at ‘ belief. | further authorize PRC and other agencies to | affiant exhibited to me his/her valid government issued 1D investigate the authenticity of ali the documents presented. issued at on Signature Over Printed Name Position 4 ~ (Notary Public) _ Date : a oe Part ill. Action Taken / CPD Division: os Reviewed by: Atty. MARIA LIZA M. HERNANDEZ if Profession ent (CPD) £ _Chie ACTION TAKEN BY THE CPD COUNCIL Disapproved A Approved for Credit Units Accreditation No. Deferred pending compliance Member Member Chairperson | Date. |

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369 ANNEX “E" PROCEDURE FOR ACCREDITATION OF CPD PROGRAM | Step 1. Secure Application Form at the Continuing Professional Development (CPD) Division or download at PRC website (www.prc.gov.ph). _ Step 2. Fill-out Application Form and comply the required documents. Application should be filed in one (1) | | ' original signed with the complete requirements with folder and fastener. (Please provide one (1) set for receiving copy) and assessment. Step 3. Proceed to Continuing Professional Development (CPO) Division processing window for evaluation sitep 4. Pay prescribed fee {in cash, Postal Money Order, Manager's Check. Bank Draft payable to Professional Regulation Commission) of One Thousand Pesos {P 1,000.00) per offering of the program. Step 5. Submit Application Form with attached supporting documents and a photocopy of official receipt to the Continuing Professional! Development (CPD) Division designated window, CHECKLIST OF REQUIREMENTS ] SUPPORTING DOCUMENTS

• Specific course Objectives ‘stating competencies to be gained from program Evaluation tool specific to course objectives set Instructional Design Program of Activities showing time/duration of topics/workshop Resume of Speakers for program applied for, showing expertise in the topic/s; show certificates or citations (if any) Current Prof. 1D of speaker if registered professional: if foreigner, current Special Temporary Permit, if applicable Breakdown of expenses for the conduct of the program £1 Additional Requiremenis: Short brown envelope for the Certificate of Accreditation One set of metered documentary stamps worth Twenty-Five Pesos (P25.00) to be affixed to the Certificate of Accreditation. (Available at PRC Customer Service and PRC Regional Offices) Be . Application for accreditation should be filed 45 days before the offering of the program/training. . Representative/s filing application/s for accreditation and claiming the Certificate of Accreditation in . The period for processing the application is 45 days. . lf additional requirement/s is/are needed, a period of 15 days is given to submit the same. Failure to behaif of the applicant must present a letter of authorization and valid identification cards of both the authorized signatory and the representative. comply within the period shal! be construed as abandonment of application and the prescribed fee shal! be forfeited in favor of the government.

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370 ANNEX “F” Professional Regulation Commission COMPLETION REPORT ON CPD PROGRAM CPD Council of NURSING Part i. General information Name of Provider: Accreditation No.: Expiry Date: Contact Person: Designation: Contact No.: Part ll. Program Accreditation Title of the Program: Accreditation No.: ‘Date of Accreditation: Date Started: Date Completed: Place / Venue: “Total Number of Participants: Date Applied: Executive Summary: . Acknowledgment _ EBY CERTIFY that the above information written by me are true and correct to the best of my knowledge and belief. | further authorize PRC and | other agencies to investigate the authenticity of all the _ documents presented. Signature Over Printed Name Position Date SUBSCRIBED AND SWORN to before me this : day of 20 al: affiant exhibited to me his/her valid government issued ID issued at on =< « i (Notary Public)

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371 ANNEX “F PROCEDURE FOR COMPLETION REPORT _ Step 1. Secure Application Form at the Continuing Professional Development (CPD} Division or download ! at PRC website (www.prc.gov.ph). Step 2. Fill-out Application Form and comply the required documents. Please provide one (1) set for receiving copy. Step 3._ Proceed to Continuing Professional Development (CPD) Division processing window for submission. CHECKLIST OF REQUIREMENTS SUPPORTING DOCUMENTS List of Participants (Name & PRC License No.) 7 List of Lecturers, Resource Speakers, etc. (Name & PRC License No.) Actual Program of Activities Summary of evaluation of Speakers in Tabular Form Summary of the evaluation of the Program offered Others 2) ee [9 Seeereerenreereny Completion Report must be submitted within thirty (80) calendar days after the CPD program offering.

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372 AM Republic of the Philippines Professional Regulation Commission Manila PROFESSIONAL REGULATORY BOARD OF NURSING Resolution No. 21_ Series of 2017 OPERATIONAL GUIDELINES FOR THE IMPLEMENTATION OF RA10912, OTHERWISE KNOWN AS THE “CONTINUING PROFESSIONAL DEVELOPMENT (CPD) ACT OF 2016” FOR NURSING WHEREAS, Section 2 of Article 1 of the Republic Act (RA) No. 8173, otherwise known as the “Philippine Nursing Act of 2002", provides for the policy of the State to regulate and professionalize the practice of profession, fo wit: “Section 2. Declaration of Policy. — it is hereby declared the policy of the State to assure responsibility for the protection and improvement of the nursing profession by instituting measures that will result in relevant nursing education, humane working conditions, better career prospects and a dignified existence for our nurses. The State hereby guarantees the delivery of quality basic health services through an adequate nursing personne! system throughout the country.”; WHEREAS, under Section 15 of Article 1V of Republic Act 10912. otherwise known as the “Continuing Professional Development (CPD) Act of 2016", the Professional Regulatory Boards (Board) are given the authority to prescribe their own requirements or procedures relating to the CPD as may be pertinent and applicable to their respective professions, PROVIDED, that the same does not contravene any of the provisions of RA 10912 and its Implementing Rules and Regulations (IRR); WHEREAS, after a series of consultative meetings with the relevant interested partners, it was i that terms relevant to the nursing profession (Annex A) and other CPD requirements be for effective implementation of the CPD Programs for nursing such as the Framework WHEREAS, the nurses have to expand ther know f cities of the H are ni and demands ces. and that in line with mee ASEAN Core international and globai standal to meet these challenges NOW THEREFORE, the Professional Regulatory Board of Nursing (Board) hereby RESOLVED. as it now RESOLVES, to formulate its own Operational Guidelines of the CPD Program in accordance with the provisions of RA 10912 and its Implementing Rules and Regulations, as follows: Section 1. Date of Regular Meetings. — The CPD Council for Nursing, under the supervision of the Board, is hereby mandated under this Resolution to meet every last Friday of the month for the purpose of evaluating the applications for accreditation as CPD provider, program, self- directed learning, and other modalities for lifelong learning and other CPD-related matters. Section 2. List of Additional Requirements for Accreditation of CPD Provider. ~ The list of documentary requirements for accreditation of CPD Local and Foreign Providers as provided for in Resolution No. 1032, s. of 2017, shail also include the following, but not limited to: P. PAREDES ST.. SAMPALOC. MANILA, PHILIPPINES, 1008 P.O. BOX 2038, MANILA

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373 APPENDIX O AMENDED CODE OF ETHICS FOR NURSES AMENDED CODE OF ETHICS FOR NURSES Pursuant to Section 3 of Republic Act No. 877, known as the Philippine Nursing Law, and Section 6 of P.D. No. 223, the amended Code of Ethics for Nurses recommended and endorsed by the Philippine Nurse Association was adopted to govern the practice of nursing in the Philippines. A new Code of Ethics for Registered Nurses has been promulgated by the Board of Nursing, in coordination in consultation with the Accredited Professional Organization (PNA). In its information, the Code of Good Governance for the Professions was adopted and integrated, as they apply to the Nursing Profession. After consultation on October 23, 2003 at IloiloCity with the accredited professional organization of registered nurses, the PNA, and other affiliated organizations of registered nurses, the Code was adopted under Republic Act 9173 and promulgated by the Board of Nursing under resolution No. 220 Series of 2004 last July 14, 2004. ARTICLE I PREAMBLE Sec. 1. Health is a fundamental right of every individual. The Filipino registered nurse believing in the worth and dignity of each human being, recognizes the primary responsibility to preserve health at all cost. This responsibility encompasses promotion of health, prevention of illness, alleviation of suffering, and restoration of health. However, when the foregoing are not possible, assistance towards a peaceful death shall be his/her obligation. Sec. 2. To assume this responsibility, registered nurses have to gain knowledge and understanding of man’s cultural. social, spiritual, psychological. and ecological aspects of illness, utilizing the therapeutic process. Cultural diversity and political and socio-economic status are inherent factors to effective nursing care Sec. 3. The desire for the respect and confidence of clientele, colleagues, co-workers, and the members of the community provides the incentive to attain and maintain the highest possible degree of ethical conduct. ARTICLE 2 REGISTERED NURSES AND PEOPLE Sec. 4. Ethical Principles 1. Values, customs, and spiritual beliefs held by individual shall be represented. 2. Individual freedom to make rational and unconstrained decisions shall be respected. 3. Personal information acquired in the process of giving nursing care shall be held in strict confidence. Sec. 5. Guidelines to be observed Registered Nurse must (a) consider the individuality and totality of patients when they administer care; (b) respect the spiritual beliefs and practices of patients regarding diet and treatment; (c) uphold the rights of individuals; and (d) take into consideration the culture and values of patients in providing nursing care. However, in the event of conflicts, their welfare and safety must take precedence.

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374 ARTICLE DI REGISTERED NURSE AND PRACTICE Sec .6. Ethical Principles 1. Human life is inviolable 2. Quality and excellence in the care of patients are the goals of nursing practice. 3. Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability. Sec. 7. Guidelines to be observed Registered Nurses must (a) Known the definition and scope of nursing practice which are in the provisions of R.A. No. 9173, known as the “Philippine Nursing Act of 2002” and Board Res. No. 425, Series of 2003, the “Rules and regulation Implementing the Philippine Nursing Act of 2002”, (the IRR); (b) be aware of their duties and responsibilities in the “Philippine Nursing Act of 2002” and the IRR; (c) acquire and develop the necessary competence in knowledge, skills, and attitudes to effectively render appropriate nursing services through varied learning situations; (d) if they are administrators, be responsible in providing favorable environment for the growth and development of Registered Nurses in their charge; (e) be cognizant that professional programs for specialty certification by the BON are accredited through the Nursing Specialty Certification Council (NSCC); (f) see to it that quality nursing care and practice meet the optimum standard of safe nursing practice; (g) insure that modification of practice shall consider the principles of safe nursing practice; (h) if in the position of authority in work environment, be morally and legally responsible for revising a system of minimizing occurrences of ineffective and unlawful nursing practice; and (i) ensure that patient’s records shall be available only if they are to be issued to those who are professionally and directly involved in their care and when they are required by law. Sec. 8. Ethical Principle Registered Nurses are the advocates of the patients. they shall take appropriate steps to safeguard their rights and privileges. Sec. 9. Guidelines to be observed Registered Nurses must (a) respect the “Patients” Bill of Rights” in the delivery of nursing care; (b) provide the patients or their families with all pertinent information except those which may be deemed harmful to their well-being; and (c) uphold the patients’ rights when conflict arises regarding management of their care. Sec. 10. Ethical Principle Registered Nurses are aware that their actions have professional, ethical, moral an legal dimensions. They strive to perform their work in the best interest in all concerned. Registered Nurses must (a) perform their professional duties in conformity with existing laws, rules, regulations, (b) measures, and generally accepted principle of moral conduct and proper decorum; (c) not allow themselves to be used in advertisement that should demean the image of the _ profession (i.e., indecent exposure, violation of dress code, seductive behavior, etc.); (d) decline any gift, favor or hospitality which may be interpreted as capitalizing on patients; (e) not demand and receive any commission, fee or emolument for recommending or referring a patient to a physician, a co-nurse or another health care worker; not to pay any commission, fee or other compensations to one referring or recommending a patient to them for nursing care; (f) avoid any abuse of the privilege relationship which exists with patients and of the privilege access allowed to their property, residence or workplace.

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Sec. 11. (a) (b) Sec. 12. 375 ARTICLE IV REGISTERED NURSES AND CO-WORKERS Ethical Principles The Registered Nurse is in solidarity with other members of the healthcare team in working for the patient’s best interest. The Registered Nurse maintains collegial and collaborative working relationship with colleagues and other health care providers. Guidelines to be observed Registered Nurses must (a) (b) (c) (d) (©) @ (g) Sec. 13. Sec. 14. maintain their professional role/identity while working with other members of the health team; conform with group activities as those of a health team should be based on acceptable, ethics-legal standards; contribute to the professional growth and development of other members of the health team; actively participate in professional organizations; not act in any manner prejudicial to other professions; honor and safeguard the reputation and dignity of the members of nursing and other professions; refrain from making unfair and unwarranted comments or criticisms on their competence, conduct, and procedures; or not do anything that will bring discredit to a colleague and to any member of other professions; and respect the rights of their co-workers. ARTICLE V REGISTERED NURSES, SOCIETY, AND ENVIRONMENT Ethical Principles The preservation of life, respect for human rights, and promotion of healthy environment shall be a commitment of a Registered Nurse. The establishment of linkages with the public in promoting local. national. and international efforts to meei health and social needs of the people as a contributing member of society is a noble concern of a Registered Nurse. Guidelines to be observed Registered Nurses must a. be conscious of their obligations as citizens and, as such, be involved in community concerns; b. be equipped with knowledge of health resources within the community, and take active roles in primary health care; c. actively participate in programs, projects, and activities that respond to the problems of a society; a. b. Sec. 15. 1s 2. 3. lead their lives in conformity with the principles of right conduct and proper decorum; and project an image that will uplift the nursing profession at all times; ARTICLE VI REGISTERED NURSES AND THE PROFESSION Ethical Principles Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal. Compliance with the by-laws of the accredited professional organization (PNA), and other professional organizations of which the Registered Nurse is a member is a lofty duty. Commitment to continual learning and active participation in the development and growth of the profession are commendable obligations. Contribution to the improvement of the socio-economic conditions and general welfare of nurses through appropriate legislation is a practice and visionary mission.

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376 Sec. 16. Guidelines to be observed Registered Nurses must a. b. & d Sec. 17. be members of the accredited professional organization which is the PNA. strictly adhere to the nursing standards; participate actively in the growth and development of the nursing profession; strive to equitable socio-economic and work conditions in nursing through appropriate legislation and other means; and assert for the implementation of labor and work standards. ARTICLE VII AMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY The Certificate of Registration of the Registered Nurse shall either be revoked or suspended for violation of any provisions of this Code pursuant to Sec. 23 (f), art, IV of R.A. No. 9173 and Sec. 23 (f), rule III of Board Res. No. 425, series of 2003, the IRR.

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377 APPENDIX P GUIDELINES IN THE ESTABLISHMENT AND IMPLEMENTATION OF AGENCY STRATEGIC PERFORMANCE MANAGEMENT SYSTEM (SPMS) Republic of the Philippines CIVIL SERVICE COMMISSION Bans sa tazm 4045) MC No. © ,s. 2012 MEMORANDUM CIRCULAR TO : ALL HEADS OF CONSTITUTIONAL BODIES; DEPARTMENTS, BUREAUS AND AGENCIES OF THE NATIONAL GOVERNMENT; LOCAL GOVERNMENT UNITS; GOVERNMENT-OWNED AND/OR CONTROLLED CORPORATIONS (GOCCs) WITH ORIGINAL CHARTERS; AND STATE UNIVERSITIES AND COLLEGES SUBJECT : Guidelines in the Establishment_and implementation of Agency Strategic Performance Management System (SPMS) ltem 14 (d) of the Joint Resolution No. 4 (Governing Principles of the Modified Compensation and Position Classification System and Base Pay Schedule of ed Government) of the Congre S$ of the Philippines. states that “a portorms based ! S performance performance management system approved by the csc andor through length of service. in accordance with the rules and regulations to be promulgated jointly by the DBM and the CSC.” Item 17 (c) of Joint Resolution No. 4 likewise states that ‘the CSC, in developing the Performance Management System, shall ensure that personne! performance shall be linked with organizational performance in order to enhance the performance orientation of the compensation system.” Section 5 of Administrative Order No. 241 provides that “agencies shall institute a Performance Evaluation System based on objectively measured output and performance of personnel and units, such as the Performance Management System-Office Performance Evaluation System developed by the CSC’. Further, Administrative Order No. 25 dated December 21, 2011, was issued with the end in view of developing a collaborative mechanism to “establish a unified and integrated Results-Based Performance Management System (RBPMS) across all departments and agencies within the Executive Branch of Government incorporating a common set performance scorecard, and creating an accurate, accessible, and up-to-dale government-wide, sectoral and organizational performance information system.” Ina Race to Serve; Responsive, Accessible, Courteous and “fective Public Service ES CSC Building, IBP Road, Constitution Hills, 1226 Quezon City * ® 931-7935/931-7939/931-8092 + escohii@webmail.esecovnh« @ www ree anaenh

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378 In view thereof, the Commission has promulgated in CSC Resolution No. 1200481 dated March 16, 2012, the attached Guidelines in the Establishment and Implementation of Agency Strategic Performance Management System (SPMS). All policies and issuances of the Commission which do not conform to the attached guidelines are superseded, repealed, amended or modified accordingly. These guidelines shall take effect immediately.

• DUQUE Ill, MD, MSc Chairman

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379 APPENDIX Q RULES OF PROCEDURES IN HANDLING CONSUMER COMPLAINTS FOR VIOLATION OF THE CONSUMER ACT OF THE PHILIPPINES (REPUBLIC ACT NO. 7394) Republic of the Philippines Department of Health OFFICE OF THE SECRETARY AUG 24 2017 ADMINISTRATIVE ORDER No. 2017 -_O01F SUBJECT: Rules of Procedures in Handling Consumer Complaints for Violation of the Consumer Act of the Philippines (Republic Act No. 7394) IL RATIONALE The Department of Health (DOH) is one of the implementing agencies tasked to enforce the mandate of Republic Act No. 7394 and its implementing rules and regulations veath Tespect to toda, drugs, Cosmetics, devices and hazardous substance. Republic Act No. 7394 confers to the DOH the authority to commence an investigation upon petition or letter-complaint from any consumer, or upon finding a prima facie violation of any provisions of said law or any rules or regulations promulgated under its authority. "As such, the DOH together with the Department of Trade and Industry (DTI) and the Department of Agriculture (DA) issued ‘Joint DTI- DOH-DA Administrative Order No. 1, Series of 1993’ in order to establish rules of procedures for consumer complaints. However, these rules needs to be amended to Be more responsive and bett ied to DOW’ s new o complaints, assuring as fi cable, simple and consumer to seek redress for their grievances. The conduct of such investigation or inquiry is vested to qualified Consumer Arbitration Officer (CAO) designated by the Secretary of Health. The CAO, pursuant to Article 162 of R.A. 7394, shall have original and exclusive jurisdiction to mediate, ——- —eoneiliate; hear-and-adjudicate-all-consumer-complaints. — Hi. OBJECTIVES A, General Objective Consistent with the policy of the State to protect the interest of the consumer and promote their general welfare, this Administrative Order is promulgated to implement measures to protect the consumer against hazards to health and safety, deceptive, unfair and unconscionable sales acts and practices; and provide consumers with adequate means of redress. B. Specific Objective This Administrative Order is also issued to enhance the procedures and provide coherence for systematically logging in, investigating and responding to consumer complaints, assuring as far as practicable, accessibility on the part of the consumer to seek redress for their grievances. Building 1, San Lazaro Compound, Rizal Avenue, Sta, Croz, 1003 Manila ¢ Trunk Line 651-7800 local 1113, 1108, 1125 Direct Line: 711-9502; 711-9503 Fax: 743-1829 @ URL: http://www.doh.gov.ph; e-mail: officeofsoh@doh.gov.ph

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380 I. SCOPE OF APPLICATION This Administrative Order shall apply to consumer complaints filed before the DOH against individual, partnership and corporation or association with respect to the commerce or consumer transaction of food, drug, cosmetic, device and/or hazardous substance in violation of any of the provisions of Republic Act No. 7394 which the DOH is tasked to implement. This Administrative Order however, does not apply to motu proprio actions and anonymous complaints which are under the authority of the Food and Drug Administration (FDA) and shall proceed in accordance with the applicable provisions of the Uniform Rules of Procedures under Book III of the Implementing Rules and Regulations (IRR) of Republic Act No. 3720, as amended by R.A. 9711 otherwise known as the “The Food and Drug Administration Act of 2009” and its IRR. IV. DEFINITION OF TERMS For purposes of this Administrative Order, the following terms or words and phrases shall be understood as follows: {A) Consumer refers to a natural person who is a purchaser, lessee, recipient or prospective purchaser, lessor or recipient of consumer products, services or credit of which the DOH has jurisdiction. (B) Consumer complaint refers to a sworn written statement of ultimate facts filed by any consumer charging any person (oataral or see who sponsible therefin Ww eet 1 m in violation of any of the prov isions of Republic Act No. TBO4 or its IRR, which the DOH is tasked to implement. (C) Complainant refers to a consumer who files a complaint to seek redress of his grievances before the Department of Health or its regional offices that has jurisdiction over the case for violation of any of the provisions of Republic Act No. 7394 or its IRR, which the DOH is tasked to implement. () Natural Person refers to an individual with civil] personality under the law. (E) Juridical Person refers to an entity other than a natural person. (F) Entity without Juridical Personality refers to two or more persons associated in any business who transact under a common name, whether it comprises names of such persons or not. In such case, the association may be sued under their common name. . dy”

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(6) Consumer Arbitration Officer (CAO) refers to a qualified officer pursuant to R.A. 7394 who has original and exclusive jurisdiction to mediate, conciliate, hear and adjudicate all consumer complaints. In case the officer performing the functions of the CAO is only designated by the SOH, he/she shall be referred to as the Acting Consumer Arbitration Officer (ACAO), GENERAL GUIDELINES A. The consumer’s best interest, promoting just, speedy and inexpensive resolution of consumer complaints shall be considered in the interpretation of these rules. The Rules of Court shall be suppletorily applied in the absence of applicable rules and procedures in this Administrative Order. The technical rules on evidence prevailing in courts shall not be strictly applied in resolving consumer complaints. The administrative adjudication of cases under this Administrative Order shall be summary in nature, providing for a simple and accessible redress for the consumer’s grievances. The complaint shall be filed using the prescribed forms or in writing with necessary verification and certificate of non-forum shopping. It shall state among others, the-following: Li the name the con and respor b. A brief statement of fact ing the background and the partic act/s and/or omission’s complained of, the approximate time of the commission of the offense or the approximate time of the discovery of such commission; c, Sworn statement/s of witness and/or documentary evidence, if any; d. The relief prayed for and preliminary or preventive measures or orders sought; and e. Such other matters or details that shall guide the Arbitration Officer in appraising the nature of the complaint and the extent of the violation/s committed. ‘The following pleadings and motions are prohibited: a. Motion to dismiss, except based on lack of jurisdiction, which must be raised at the earliest opportunity; b. Motion for judgment on the pleadings or summary judgment; c. Motion for extension of time to file answer, affidavit, position paper and other similar pleadings; d. Motion to Intervene; : ) a 381

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382 Motion for Bill of Particulars; Counterclaim or Cross-Claim; Dilatory Motion for Postponement; Motion for Reconsideration of interlocutory orders or interim relief orders; Third Party Complaint; Second Motion for Reconsideration; Reply; 1. Rejoinder; or m. Memorandum of any kind. rE ho REO G. The filing or pendency of a consumer complaint shall not preclude the parties from pursuing proper judicial action. Notwithstanding, the Consumer Arbitration Officer shall independently proceed with the investigation and shall render a decision. VI. SPECIFIC GUIDELINES For the information, guidance and compliance of all concerned, the following uniform rules of procedures in the administration/resolution of consumer complaints filed before the DOH or its regional offices with respect to food, drug, cosmetic, device and substance, pursuant to the provisions of Republic Act No. 7394, is hereby institutionalized as follows: 1 VENUE t shall have the option where to file the complaint which 1.1. The compl may be t ie py i x (c) the complainant resi 2. PARTIES 2.1. The complainant must be a natural person and the subject of the complaint is a consumer product or service as defined under the Consumer Act. Meanwhile, the respondent may be a natural or juridical person. 2.2. Complaint against entity without juridical personality may be filed under their common name. 3. COMMENCEMENT OF ACTION 3.1. An action is commenced upon filing of a verified complaint or a duly accomplished Affidavit Complaint Form (Appendix A) attested by the Consumer Arbitration Officer (CAO) or any person authorized to administer oath. bp.

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3.2. Anonymous complaint shall be endorsed to FDA for verification/investigation and shall proceed as an FDA initiated action pursuant to its Uniform Rules of Procedure. JURISDICTION/POWERS AND DUTIES OF CONSUMER ARBITRATION OFFICER 4.1. Jurisdiction. The Consumer Arbitration Officer shall have original and exclusive jurisdiction to mediate, conciliate, hear and adjudicate all consumer complaints filed within the territorial jurisdiction of the office where the CAO is assigned. 42, Powers and Duties Summon witnesses; Administer oaths and affirmation; Conduct the mediation/arbitration hearing as scheduled; Regulate the proceedings and maintain order during the hearing; Issue subpoena ad testificandum or duces tecum when requested to compel attendance of witnesses or production of documents during the hearing; £ Receive all relevant evidence which may help in giving a fair decision/award; g. Rule upon offers of proofs; bh. Take or cause deposition when necessary to serve the ends of justice; i. Rule on any procedural request on similar matters: Ss Re op ea ion Was termina bo Issuance of Summons. If the CAO believes, based on the allegations of the complaint and the supporting evidence, that prima facie case exists, summons shall be issued against the respondent, copy furnished the complainant, requiring the respondent to file a written answer. bs 4.4. Filing of Answer. The respondent shall be required to file an answer within a non-extendible period of ten (10) days from receipt of notice/summons issued by the CAO. Respondent’s answer shall include sworn statement of witness/es and documentary evidence, if any, a copy of which shall be served to the complainant with proof of service. Failure to file answer shall be construed as waiver to submit the same and decision shall be rendered based on the records submitted. MEDIATION 5.1. Mediation Conference. The CAO shall first ensure that the parties come to a settlement and conduct a mandatory Mediation Conference for that : ie 383

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384 purpose. No consumer complaint shall be submitted for adjudication without passing this stage. The mediation proceedings shall be confidential and any information disclosed therein shall not be used or admitted in evidence during the adjudication proceeding or in any other proceeding except when confidentiality is waived in writing by both parties. 5.2. Notice and Schedule of Mediation. Within five (5) days from receipt of the verified complaint, the CAO shall issue a written Notice of Mediation, setting the date which shall not exceed thirty (30) days from the receipt of the verified complaint, time and place of the mediation conference and serving copies to all parties through either personal service, postal service, private courier or other acceptable means with proof of service. No lawyer shall appear on behalf of or represent a party at the mediation conference, unless the lawyer is the complainant or respondent. 5.3. Period for Mediation Proceeding. The mandatory mediation proceeding shall in no case exceed thirty (30) days from the date when the first mediation conference was set. During that period, more than one (1) mediation conference may be held which shall be personally attended by the parties. 5.4. Postponement. Request for postponement and resetting of the mediation conference is allowed, provided that the entire mediation proceeding shall not exceed the thirty (30) day period. Any request for postponement shall be in writing, made t three (3) days bef I ce _ and with proof of servi otice to the other party. Mediation Agreement. Any agreement setting the parties’ dispute shal] be in writing, signed by the parties or their authorized representatives and attested by the CAO, In case settlement was reached by the parties without the assistance of the CAO, the agreement shall likewise be in writing, notarized and submitted to the CAO. w in The CAO shall then render judgement based on the compromise agreement which shall be final, executory and binding upon the parties and shall have the force and effect of an adjudication of the case. 5.6. Termination of Mediation. In case no agreement is reached by the parties after the lapse of thirty (30) days, the CAO shall issue an Order terminating the mediation proceedings. The said notice or order may be made through personal service, postal service, private courier or other acceptable means with proof of service.

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385 APPENDIX R SAMPLE QUALITY IMPROVEMENT PLAN Planned improvement initiatives (Change Ideas) Methods Process measures rget for process measure Comments a)introduction of a utilization management tool. Daily review of all patients who have targeted estimated length jof steys and planned discharged dates as a means of proactive preparedness pre- discharge. Reviewing daily report of all patients to be discharged within 24 hours to address and resolve any barriers to discharge. 400% of patients wil! be reviewed 7 days a week N/S 2)}Launch of "Helping Hands". Ail patients whose acute care stay is completed, who are waiting to be discharged to their permanent destination will be transferred to Helping ands on an interim besis until such permanent destination is jprepered or available. All patients suitable te transition to Helping Hands will be transferred provided capacity is available. Helping Hands to be faunched Fall 2017. N/& 3)4ppropriate edmissions criteria. Development of a process and criteria for patients arriving in the ED without an acute diagnosis will be transitioned safely ta an apprepriate destination, ensuring only these with acute care needs to be admitted. Through the consultation and colleboration of 2 variety of sub- speciaity physicians, the criteria will be developed. Appropriate admissions criteria will go live commencing 3 2017. N/A sment Time, 2jNurse assigned to waiting room for patient reassessment/ EMS officad. Kourly rounding in waiting rooms, Leader and Senior Leader rounding in the ED. £845 offload times. Achieve 30 minute EMS Offload times. N/A 3)Redesign Triage area: both) processes and physical space. Physicians, nurses, clerks and patient advisory members utilize LEAN methodology to identify process and space improvements to reduce ED LOS and improve patient experience. Reduced time for Triage and Registration and improve patient and family experience. Achieve CTAS targets. improve patient and family experience by 2. NSA

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386 APPENDIX S TRANSFUSION STANDARD OPERATING PROCEDURES National Voluntary Blood Services Program TRANSFUSION STANDARD OPERATING PROCEDURES BLOOD REQUISITION CROSSMATCHING DISPENSING BLOOD UNIT BLOOD ADMINISTRATION MANAGEMENT OF SUSPECTED TRANSFUSION REACTION INVESTIGATION OF SUSPECTED TRANSFUSION REACTION

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PROCESS FLOW 387 A. BLOOD REQUISITION Vv CHECK DOCTOR’S ORDER FOR TRANSFUSION A SECURE INFORMED CONSENT Vv ACCOMPLISH COMPLETELY AND LEGIBLY THE BLOOD REQUEST FORM Vv SUBMIT TO BLOOD BANK U WARD NURSE B.CROSSMATCHIN G START: B Ad RECEIVE BLOOD REQUEST FORM Vv CHARGE CROSSMATCHING FEE a EXTRACT BAMPLE y CROSSMATCH A STORE BLOOD UNIT A RELEASE CROSSMATCHING RESULT FORM + C BLOOD BANK STAFF

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388 C. DISPENSING BLOOD UNIT START: C Vv RECEIVE: 1. CROSSMATCHING RESULT 2. | REQUEST FORM FOR ALIQUOTING/THAWING N CHARGF RLOAN SFRVICF FFF DO ALIQUOTING/ THAWING. IF APPLICABLE N INFORM WARD NURSE ONCE AVAILABLE (AHLOUOTING/ THAWING) Vv MATCH PATIENT'S INFORMATION IN THE CROSSMATHING RESULT, LOGBOOK, AND BLOOD UNIT LABEL A RELEASE BLOOD UNIT TO NURSING STAFF Vv U BLOOD BANK STAFF

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389 D. BLOOD ADMINISTRATIO N ENSURE A SIGNED INFORMED CONSENT Vv FNSIIRF Pl AIN NSS IV LINE A TAKE VITAL SIGNS TAKE BLOOD UNIT FROM BLOOD BANK A MATCH CROSSMATCHING RESULT FORM, BLOOD UNIT 1ARFI AND PATIFNT’S IDFNTIFICATION vy HOOK/ TRANSFUSE UNIT A MONITOR PATIENT : UNHOOK UNIT ONCE CONSUMED DISPOSE ACCORDINGLY IE WARD NURSE

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390 E. MANAGEMENT OF SUSPECTED TRANSFUSION REACTION <= START: E Vv NOTE OF SIGNS AND SYMPTOMS OF PATIENT N [ CLOSE RIQON TRANGFIISION LINF TEMPORARILY | X | TAKE VITAL SIGNS | x REFER TO PHYSICIAN ON DUTY N MANAGE ACCORNINGIV | NO N UNHOOK BLOOD UNIT v ACCOMPLISH SUSPECTED TRANSFUSION REACTION FORM SUBMIT THE FOLLOWING TO BLOOD BANK:

1. SUSPECTED TRANSFUSION REACTION FORM
2. BLOOD UNIT WITH INTACT TUBING AND NEEDLE U Continue Transfusion? YES MONITOR PATIENT CLOSELY WARD NURSE

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391 RECEIVE: BLOOD BANK

1. SUSPECTED TRANSFUSION REACTION FORM STAFF FE.
2. BLOOD UNIT WITH INTACT TUBING AND NEEDLE, AND INVESTIGATION OF SUSPECTE D TRANSFUSION EXTRACT POST-TRANSFUSION BLOOD SAMPLE REACTION | RE-CROSSMATCHING AND DO OTHER LABORATORY TESTS | REFER TO BLOOD BANK CONSULTANT FOR INTERPRETATION A ATTACH REPORT TO CHART —

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392 APPENDIX T NURSING OFFICE REQUIREMENTS Nursing Office Requirements (a) Office desk, chairs, ventilation, equipment, bookcase and books, filing cabinets for personnel records, computers, printer and communication equipment. (b) Toilet and hand washing facility (c) Trash receptacle (d) Conference Rooms with: ° 00000 Tables and chairs, blackboard Bulletin board/white board Bookcase and books Ventilation equipment Sound system Overhead projector/LCD Patient’s Unit Requirements ° Private Rooms’ Basic requirements fo} oo0o0o00 000 hospital beds with mattress bedside tables over bed tables chairs pillows linens supplies and materials for patient care cabinets toilet and hand washing facility ° Medical and Isolation Wards fo} ° Basic requirements: <_ Table wares. food tray ~ Cubicles or sereen to maintain privac: < Complete set of equipment for morni A nurses’ station with medication and treatment rooms furnished with medicine cabinets, hypo-trays, tables, syringes and needles, medicine glasses, chairs and timepiece. catment and other procedures e Intensive Care Units. The medical and surgical services must have an Intensive care unit (ICU) with the following: ° ooo0o0o0 00000 Hydraulic beds Bedside tables Monitoring machines Respirators Thermometers Kidney basins Oxygen supply Blood Pressure apparatus Emergency/Resuscitative equipment Facilities for post-operative and clinical care Emergency drugs and medicines ° Pediatric Ward. It should be equipped with the basic requirements and provided with the following: Cc. d. e. £ &. Segregated units for surgical, non-infectious and infectious cases Playroom with children’s furniture and shelves for toys Hand washing and toilet facilities, bathroom facilities that are suited for children Mothers’ rest with lockers, tables and lounging chairs Breastfeeding room/area ° Neonatal Intensive Care Unit (NICU). It should be equipped with: ° ° ° ° Bassinets Diapers changing carriage Incubator Cabinet for baby’s clothes

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oo0o00 000 393 Hand washing facilities Working table with bucket for soiled clothes Articles for baby care Proper lighting facilities Bili light Resuscitation Equipment Refrigerator for breast milk supply Dressing room area for breastfeeding Obstetrics and Gynecology Ward It should contain the following requirements ° fe} ° Wards with the basic requirements Examining rooms which include: Examining table Droplights Kelly pad Bucket with rollers Tray for external douche Instruments for internal examination Gloves Hand washing facilities VVVVVVVV Intensive Care Unit (ICU) equipped with beds usually for eclamptic and/or serious patients including toilet and hand washing facilities Dressing Room — the delivery room staff should be provided with toilet and bath, lockers and comfortable chairs Labor Room — equipped with one or two beds, toilet and hand washing facilities. Delivery Room must include: Standard delivery tables Built-in cabinets for instruments, sterile packs, drugs Anesthesia machines Resuscitation machine Good lighting facility Timepiece Instrument tables Trays Trash receptacles VVVVVVV y ‘ Breastfeeding Room / Area Refrigerator for breast milk storage Surgical Ward 3° © (69) (g) Wards — equipped with the basic requirements Utility Units — cleaning area for all materials/instruments used by patients Preparation room

Standard treatment table

Cabinets and table

Good lighting facility

Hand Washing Facility

Trash receptacle Office for Operating Room (OR) nurses

Office desk Chairs Filing cabinets Bookshelves Lockers/cabinets for OR records and reports Communication Facility Recovery Room

Resuscitation equipment VVVVVV Note: The recovery room must be adjacent to the Nurses’ Station Orthopedic Unit

Orthopedic beds with mattresses, Balkan frames, bed elevators

Suction apparatus

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394

Casting tools

Splints

Bags and other orthopedic contractures (h) Burn Unit o Bed o. Chairs o Toilet and bath o Rehabilitation equipment ° Out- patient Department (i) Consultation Room Gj) Examination facilities (k) Hand washing facility (1) Nurses’ station with tables and chairs (m) Filing cabinets (n) Audio-visual equipment (0) Health Education Area

Bulletin Board

Benches and chairs A. Emergency Room o Stretcher Bed (more than one) o Wheelchair o Resuscitation equipment o Cabinets for emergency drugs and medicines o Lighting facilities e Central Supply Service o Cabinets o Autoclave machines o Other types of sterilization o Working tables o Chairs o Utility Room

Toilet and hand washin, facihiy Physical Resources Basic components: Building (Physical lay-out, equipment and supplies) The Nursing Service Office and Nursing Units are equipped, operated and maintained to sustain its safe and sanitary characteristics and minimize all health hazards in the hospital for the protection of clientele and personnel. e Nursing Office is equipped with but not limited to: o Nursing Director’s Office Assistant Nursing Director’s Office Conference Room Mini-Library with current books and journals Lounge room with refrigerator, tables and chairs Comfort room with lavatory Cabinets for stocks and supplies Office furniture Office tables and chairs Conference tables and chairs Filing cabinet Communication equipment as:

Telephones

Computer set with printer

Typewriters

Bulletin Board

Whiteboard/Blackboard

Fax machine (optional)

Xerox machine (optional) oo0o0o000 00000

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395 e Nursing Training Office ° o0oo0°0 Conference Room Classroom with blackboard Comfort Room with lavatory Training Office/Instructor’s Office with shelves and cabinets Equipment/machines/furniture

Tables and chairs

Slide/Overhead projector

• _ Blackboard/Whiteboard

Bulletin Board

Telephones

Typewriter/computer set with printer e The Nursing Units: The Nurses’ Station is equipped with but not limited to: fo} oo0o00000000 000 oo000 000 Medication/Treatment Room with cabinets and shelves (cubby shelves for patients medicines and for treatment trays) Linen cabinet with shelves Storage Room for linen trolley, Oxygen carrier, Wheel chairs, stretchers, Suction Apparatus etc. Office for Nurse Supervisor Small conference room with blackboard and bulletin board Chairs and cabinets shelves for nursing forms Chart racks with chart covers/folders Nursing lounge with lockers, tables and chairs and refrigerator Kitchenette/pantry with electric stove and lavatory Toilet/bath/lavatory for nursing personnel Utility room with flush hopper, lavatory, sink for washing mops Nurses’ call light system Computer set Emergency cart

Emergency drugs/supplies

IV fluids with IV set and catheter

Syringes with needles

Cardiac board

Endotracheal tubes with different sizes

Laryngoscope with different sizes of blades (manual resuscitator bag) able oxygen tank with gauge and humidifier

Oxygen cannula/oxygen mask Defibrillator Medicine cart and dressing cart Patients directory Telephones BP apparatus with stethoscope; thermometers Weighing scale Color coded trash cans/bags/bins e Patients’ Unit L 2. 3. 4. 3. Toilet and bath with lavatory and occupational safety bars Lockers and shelves with provision for hangers Nurses’ call light system near beds and toilets Hand washing area Fumiture’s and fixtures

Hospital beds with mattresses/side rails and linen

Bedside tables/overhead table

Footstool

• — Chairs

Pillow

Bedpan/Urinal

Kidney basin, sputum cup

Big and small basin

Color coded trash can/bags/bins

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396 Private Rooms are equipped with but not limited to: ° ° Basic requirements Nos. 1-4 plus Additional /optional requirements

Extra bed with mattress or couch for watchers

Refrigerator

Television sets and telephones Isolation Rooms ° ° Basic Requirements of patients unit plus: Additional/optional requirements e Lavatory outside the room e Cabinet with shelves outside room e Small utility room outside the patient’s room Special Units o Machines and Equipment’s o Support service units o Fixtures Other Requirements © The units are provided with good lighting and good ventilation. o There are provisions for site plan/ diagrams / signage’s for emergency exits and safety devices like fire alarms, non-toxic human and environment-friendly fire extinguishers, smoke detection devices and water sprinkler. © There are facilities like ramps, hand-rails, comfort rooms for the disabled clientele and the public. o _Equipment’s are adequate, available and user-friendly. The nurse’s station is centrally located or at the entrance of the unit.

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397 APPENDIX U EXAMPLES OF MEMORANDUM, DIRECTIVES, ADMINISTRATIVE ORDER ~ APPENOIy p Repuutic of the Philippines Department of Health NATIONAL CHILDREN’S HOSPITAL Philhealth Accredited 18 February 2019 HOSPITAL PERSONNEL ORDER no. 2019- O71 SUBJECT: uthority for the ted staff to attend the fraining on Famil Planning Competency Based Training Level 1 on March 11-15, 2019 GLIMAP Training Center, Pasig City. i As pet inviiation from President, IMAP CAMANAVA Julieta F, Gomez, RM, BSBA dated January 26, 2019, ihe Integrated Midwives Association of the Philippines {IMAP} inc. will be conclucting a training entitled: “Family Planning Competéney Based Training Level 1 on March 11-15, 2019 at the IMAP Training Center, Pasig City. Authority is hereby given to the selecied staff to attend ! the said activity on official business. 3. Ms. Jennifer C. Espiritu 4. Ms. Prima B. Caperig Under this Order, the above-named participant shail submit a copy of Certificate of Parlicipation/Completion/Appearance to the Human Resource Management Section within five (5} working days upon return fo the hospital. desu Path ale D, FPPS, CEO Vi Medica! Center Chief Il HRMOFC “Fo achieve ail thai ix possible and te attempt even the impossitle” JAS-ANZ Address: 264 E. Rodriguez Sr, Blvd., 1102 Quezon City, Philippines ISO Website: www.nch.doh.gov.ph Email address: nch_264@yahoo.com G- eee TrunkHnes: 724-0656 to S9, 724-0650. 726-8980, 726-9125 Telefax: 721-9125

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398 Republic of the Philippines Department of Health OFFICE OF THE SECRETARY February 26, 2019 DEPARTMENT MEMORANDUM No. 2019-101 TO: CHIEFS OF DOH MEDICAL CENTERS/REGIONAL HOSPITALS AND SPECIALTY HOSPITALS SUBJECT: Submission of Details of 2018 Quantified Free Services and Other Financial Data of Ali DOH Hospitals in Preparation for 2020 Budget Proposal In line with the vision of FOURmula One (F1) Plus for health towards “Filipinos are among the healthiest people in Southeast Asia by 2022, and in Asia by 2040, through the financial strategies to secure sustainable investments to improve health outcomes and ensure efficient and equitable use of health resources. Hence it is vital to gather relevant information specifically on the Quantified Free Services (QFS) provided by DOH Hospitals to analyze the impact of the revitalized National Health Insurance Program through PhilHealth’s expansion towards universal coverage, implementation of No Balance Billing (NBB) and All Case Rate system, and other financial data for appropriate, responsive, and equitable distribution of resources among DOH Hospitals. In this regard, we would like to request your submission of the CY 2018 QFS and other financial data, Please the dota accomplis or 15, 2039 tow oy N cc 140) and 1403 or email address doh hfab, fppdd@gmail.com and trishamayi9@vahoo.com. For questions and clarifications, please feel free to contact Mr. Roderick Napulan, OIC-Division Chief, Facility Planning and Program Development Division (FPPDD) or Ms. Trisha May Sarabia, DMO I. To ensure uniformity of QFS computation, please use the formula provided below and the definitions attached herewith: Total Hospital Bill PhilHealth and third party payers | —. Balance (ie. inpatient, OP, ER) — (i.e. PCSO, MAP, HMOs, etc.) | “" QRS For your compliance. By Authority of the Secretaiy of Health: LILIBETH C. DAVID, MD, MPH, MPM, CESO TT Undersecretary of Health é Health Facilities and Infrastructure Development Team Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800loc1 113, 1108, 1135 Direct Line: 7) 1-9502; 711-9503 Fax: 743-1829e URL: hilpviwys.dloleoy.pls; e-mail: Aduque@doh.goy.ph

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399 Part I. Hospital General Profile A, Contact Details

1. Name of Hospital
2. Chief of Hospital
3. Email Address
4. Contact Number B. General Profile and Performance Indices 1, Actual Bed Capacity
5. Implementing Bed Capacity
6. Authorized Bed Capacity (Licensing) 4, Authorized Bed Capacity (Law/RA) Part IJ. Performance Indices (as of December 31, 2018) A. Total outpatient visits B. Total ER visits C, Net Death Rate D. Net Infection Rate (nosocomial) E, Total inpatient days served F. Total G. Breakdown of Inpatients:
7. Socio-economic classification based on MSW) a. Class A b, Class B c. Class Cl d. Class C2 e¢, Class C3 economy b. Individually paying or self-employed, or voluntary or members in the informal economy c. Overseas Workers d. Sponsored e. Indigent f, Lifetime g. Senior citizens h, No PhilHealth

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400 Part V. New Buildings Constructed ready for operations as of December 31, 2018 Fiscal Year 2018 A. Total Additional Beds B. Required utility costs for the operations: 1, Electricity Expenses 2, Water Expensed 3. Telephone-Mobile 4. Telephone-Landline 5. Internet Subscription-Expenses 6. Other Maintenance and Operating Expenses 7. Total Part VI. Income Statement (as of December 31, 2018) Fiscal Year 2018 A. Revenues i. From Department of Health a. GAA PS b. GAA CO c. GAA MOOE d. SAA from HFEP e. SAA from MAIP f£. SAA from other program units __ 2. From Hospital Income (excluding PHIC) | p s-] al Fees — Operating Room sgerwamnsenll . —__| c. Medical Fees ~ Radiology ! d. Medical Fees — Laboratory i ¢. Medical Fees —- Hemodialysis f. Medical Fees —- Cardiovascular Services g. Medical Fees — Pulmo Services h. Rent/Lease income i, Seminar/Training Fees j. Other Business Incom 3. Other revenues a. PhilHeatth a.1. For hospital a.2. for professional fees b. Reimbursement from private insurance c. From development partners d. From private organizations e, From other organization e.1. PCSO e.2, PAGCOR

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e3, DSWD 4, others B. Expenses

1. Total amount for personnel a. Spent on personnel salaries and wages b, Spent on benefits for employees c, Spent on allowances provided to employces
2. Total amount on investments a, Spent on infrastructure b. Spent on equipment c. Spent on other long-term income generating activities.
3. Total amount on operations a, Spent on medicines b. Spent on medical supplies c. Spent on utilities d. Spent on rent €, Spent on maintenance of hospital premises/equipment £. Spent on job order personnel or contract of service g. Spent on administrative supplies and equipment h. Spent on professional services i. Spent on other operating expenses not stated above
4. Total amount of other expenses not specified above 401

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402 Definition Used for the computation of QFS Quantified Free Service is the portion of the total hospital bill after deducting the out-of-pocket collections, financial assistance including Medical Assistance Program (MAP), PCSO, DSWD, LGU Support (GUMAP and Isabela HealthCare) and Philhealth Benefits. This also represents Senior Citizen (SC) discounts and NBB reimbursements based on the No-Balance-Billing Policy. This portion of the total hospital bill is categorized per AO No. 51-A. Discounts pertaining to Senior Citizen, Persons with Disability and MSS Classification were granted to patients at OutPatient Department and Emergency Department, however, only records on number of patients who availed of discounts were found but no tecords on the monetary value of the said discounts. Portion of the QFS on NBB Policy consist of the amount of total hospital bill after deducting the Philhealth Benefits and Out-of- " Pocket Collections. QFS for Inpatients categorized per AO 51-A represents discounts granted to service/charity and Non-Sponsored Philhealth patients.

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403 APPENDIX V MONITORING AND EVALUATION OF THE NURSING SERVICE Standards Indicators Validation Data Collected YES/NO Remarks There is a plan of organization to implement and facilitate achievement of the nursing service Organizational chart updated Data Validation Presence of Overall objectives of the nursing service Presence of objectives written Data validation Describes responsibility, authority and accountability of the service Define areas of responsibilities written Data validation There is a chart of organization which is directed by a qualified nurse administrator Presence of organizational chart Data validation Vision, mission, Written Data validation philosophy and core values are written Available hospital nursing service policy manual Written / updated Data validation Available Nursing Procedure Manual Written Data validation ( Work Instructional updated Manual ) Presence of policies that Written Data validation apply to patients updated Presence of policies that Written Data validation apply to personnel updated Presence of policies that Written updated Data validation apply to environment Policies and Procedures are a distributed in each Nursing | Written updated Data validation Unit Presence of operational Written Data validation plan reviewed

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404 Standards Indicators Validation Data Collected Remarks YES/NO Presence of Risk Written ae : Data validation management plan reviewed Written Nursing Unit has a budget plan submitted Included in the work and financial plan Data validation Presence of a written Code of Ethics which observes the rights and safety of Waitten, Data validation patient and health care providers Actively participate in nursing professional Written organization for continuous quality improvement Lists of organization Data validation Presence of Chief Nurse who is qualified to the written Data validation position based on RA 9173 Established master staffing Reviewed Data-valiaation plan written Established Master rotation otter Data validation plan Adequate staffing | Written Data validation maintained Ratio of staff Approved number of position are filled up Written Number of unfilled position Data validation Copies of time schedule ; Written ae are posted in the nursing Data validation : updated unit il atient Writt sae Dat y Nurse p 3 en Data validation assignment every shift updated The licensure, education, trainings , seminars of Written bia ainings » y Data validation nursing personnel updated documented Established system and process for recruitment, selection , hiring, written Data validation appointment and promotion Participate in various Written P Lists of hospital Data validation hospital committees committees

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Data Collected Standards Indicators Validation YES/NO Remarks Participate in various nilten. F E ‘ . List of nursing service sags Nursing service z Data validation committees committees Reports submission Available written job description for each zs : : written Data validation position with specific duties and responsibilities Available learning and development intervention plan Written In — service program Outside hospital Lists of LDI program Data validation Established orientation program for newly hired personnel, promotes staff, with syllabus Written Data validation Available safety program for nursing service written Data collection Established nursing endorsement every shift Conduct pre conference every shift written Data validation Available kardex in each nursing units updated Data validation Established nursing standard documentation FDAR Written updated Data validation Conduct nursing service meeting Written Minutes of meeting Data validation Established nursing audit policy writen Data validation Conduct nursing audit Established cai program Written Data validation in the nursing service lists Established reporting system on the quality and written Data validation safety programs Established checking and monitoring of drugs and written Data validation equipment every shift Written Conduct nursing research Lists of nursing research conducted Data validation

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406 APPENDIX W NURSING SERVICE BI— ANNUAL REPORT FORM NURSING SERVICE MONTHLY REPORT FORM Region/ Province: Name of Hospital: Date Accomplished: Address: Bed Capacity: e NURSING PERSONNEL CATEGORY AUTHORIZED Chief Nurse Bed Occupancy (%): ACTUAL Asst. Chief Nurse Supervisor Senior Nurse OR Nurse Staff Nurse Nursing Attendant Ward Clerk Others, Specify TOTAL e PERSONAL RECORD: (For last month) o Attendance Number of 1.1 Absence without leave Number of 1.2 Vacation leave 1.3 Sick leave 1.4 Maternity leave 1.5 Others (Pls. Specify) TOTAL o Resignation and Hiring of Nurses 2.1 Number of Nurses who resigned last month 2.2 Number of Nurses who were hired last month o Resignation and Hiring of Nursing Attendants 3.1 Number of Nursing Attendants who resigned last month 3.2 Number of Nursing Attendants who were hired last month

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407 o Number of Nursing Personnel who attended continuing education programs (in-service or outside) TOPICS DATE NO. OF HOURS e EQUIPMENT AND SUPPLIES 1. Are there new equipment used by nursing personnel? YES = NO __ 1.1 What are these? 1.2 Date of Acquisition: 1.3 Do they know how to operate these? 2. Do you have adequate budget for the following supplies per month: YES NO Medical Housekeeping Office Others, please specify e REPORTS 1. What were the reports by the nurses last month? Name of Report Who prepared the Report Frequency — Submitted to e INCIDENT REPORTS (For the past 6 months, summarize the number and nature of problems/ incidents written about) and actions taken. e ACCOMPLISHMENTS A. Patient Care

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408 B. Training/Continuing Education/Program/Activities C. Research D. Extension Services E. Number of Students affiliating in the hospital (last month) o Nursing o Midwifery o Nursing Aide