SYNOPSIS FOR NURSING EXCELLENCE

1 - NURSING RESOURCE MANAGEMENT (NRM)

Objective Elements Interpretation / Remarks
NRM.1 - The organisation has a documented system of nursing resource planning
1. A yearly nursing plan
a) Nursing resource planning 2. Contingency plan
3. As per INC guidelines
b) Adequate staffing for service needs of the
Nursing staff should be commensurate with work load
patient
INC recognized qualifications with management
c) Qualification of nursing head
training / degree.
As per INC guidelines / MOHFW hospital manual
d) Experience for nursing head
guidelines.
e) Job specification and job description for nursing Job description commensurate with qualification and
staff the qualification is minimum GNM / B.Sc Nursing
NRM.2 - The organisation has structures and processes for induction and for enhancing the
transition of novices to competent nursing professionals
a) Shift planning for various areas based on their
To handle emergency situations
skills
Allocate the training topics according to the need and
b) Training needs by senior nursing professionals
educate the employee with the concerned trainer.
c) ---------------------------
NRM.3 - The organisation has processed in place for induction training, In - service education and
Continuous Nursing Education (CNE) programmes and for documentation of the same in the
personal files
1. Training on within 15 days of joining
2. Providing booklets
a) Induction training for new nurses
3. Training should define about patient safety and
quality nursing care.
b) Policy for training and development The policy must include
1. Training needs
2. Training methodology
3. Documentation of training
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c) The organisation maintains records of training
d) Training as per job description and job
responsibilities
e) Certification on BLS for nursing staff and ACLS Training records should be documented.
or PALS or NALS for intensive care/ high
dependency as applicable.
NRM.4 There is a process for credentialing and privileging og nursing professionals, permitted to
provide patient care without supervision.
a) The education, registration, training and
experience of nursing staff is recorded and updated
periodically.
b) Nursing care without supervision is identified.
c) All such information pertaining to nursing staff
is appropriately verified when possible
d) The nursing staff has to be privileged as per
their qualification, training and experience.
e) The requisite services to be provided by the
nursing staff are known to them as well as the
various departments/ unit of the organisation
f) Nursing staff providing patient care as per their
privileging
NRM.5 An appraisal system for evaluating the performance of nursing staff exists as an integral part
of the nursing resource management process.
a) A recorded performance appraisal system
b) Awareness about appraisal system
4. Training assessment
5. Impact of training
A training calender has to be prepared.
Training records includes
1. Title of the training
2. The list of trainers and trainees with signature
3. Post - training feedback
Training should be focused on if job responsibility
changed and new equipment introduced.
Updation about education, training & experience of
nursing staff by Credentialing and privileging
committee.
Identifies the individuals who is eligible accordingly.
The Nursing staff qualification and training
certificates has to be validated.
This is supposed to decided in Credentialing and
Privileging committee.
This could be done by internal communication.
Ensure new staff are providing care only those
services that they have been privileged to offer.
Appraisal has to be done according to various
categories of nurses by the person who is heading the
nursing service.
Appraisal supposed to be explained through induction
 SYNOPSIS FOR NURSING EXCELLENCE

classes or service booklets.

1. Key result areas are identified for each nursing
c) Performance is evaluated on pre - determined
staff.
criteria
2. Training at the time of assessment
d) Performance appraisal is carried out at pre -
This shall be done at least once a year.
defined intervals ans is recorded.
NRM.6 There is a provision for acknowledging outstanding performances / contributions of nursing
professionals.
Patient, families and staff shall be encouraged to
a) Feedback for nursing care report positive feedback about nursing care delivered
in relevant areas.
b) Nursing supervisors ensure that soft skills in
nursing, qualities of leadership and professional -----------------------
competence are duly reported to higher authorities.
NRM.7 There is an established process in place to identify and manage problems related to
incompetent, unsafe or unprofessional conduct.
This includes
1. Appearance
a) Daily monitoring of appearance and ability 2. Behaviour
3. Communication
4. Decorum
b) -------------------------------------------
Nursing staff has right to explain if any complaints on
c) The disciplinary policy and procedure
him/her.
NRM.8 The organisation demonstrates workplace safety for nursing professionals (including change
rooms, washrooms & dining facilities)
There shall be sufficient change rooms, washrooms,
a) Resource for workplace safety by management
recreation rooms & dining facilities.
b) Mechanism for reporting safety related issues
Creating harassment committee to ensure workplace
c) Promoting safe environment for employees
safety for nursing professionals.
d) Record should be there for corrective and
preventive action wherever appropriate.
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NRM.9 The organisation has a documented and established grievance handling system.
a) Define process for handling nurses grievances
b) Education to know the mechanism to address the grievances
c) The head of nursing service protects nurses rights
d) Nursing professionals are educated about their rights.
2 - NURSING CARE OF PATIENT (NCP)
NCP.1 A Nursing Manual shall be established and review periodically as defined by HCO
Nursing manual to be prepared and the following
a) Standard Operating Procedures and guidelines areas should be included
for nursing care ICU, OT, Dialysis, ED, BMT, Chemotherapy,
Endoscopy, Day-care etc.
It covers Dressing trolleys arrangement, Nurse call
b) Policy on Nursing station management
system, record maintenance, Crash cart arrangement.
c) Manual contains list of various forms and
formats used by nurses.
d) Nursing manual shall be available for following.
e) Manual should be reviewed and updated once a Update as per national and international guidelines
year time to time and GCP.
NCP.2 The initial assessment shall be done by the nursing professionals in predetermined format at
prescribed time and/or as per the needs of the patients.
To find the nursing needs of the patient.
a) Initial assessment
Checklist or template could be used for the same.
This include head to foot observation, Checking of
b) Initial assessment vitals, height, weight, input-output charts and special
needs etc.
This shall be documented by the assigned nursing
c) Nursing Care Plan
staff in the patient record.
Nursing care plan include diet, drugs etc. This could
d) The documentation includes preventive aspects
done through booklets/patient information leaflets etc.
NCP.3 The reassessment shall be done by the nursing professionals in a predetermined format at
prescribed time.
Patient is reassessed periodically (at least once every
a) Patient reassessment
shift)
 SYNOPSIS FOR NURSING EXCELLENCE

Reassessment has to be documented in transfer

b) Reassessment during transferring
register/form.
c) Reassessment during before and after shifting
for investigation.
Nursing care plan is modified when emergency
d) Nursing care plan situation arise and it has to be added in the checklist
/form.
e) Evaluate outcomes using reassessment and
revise action plans
NCP.4 For provision of nursing care, appropriate number of nursing professionals shall be
maintained as per workload.
a) Nurse patient ratio based on scope of the unit. The ratio should be as per INC guidelines.
The Nurse patient ratio is monitored by nursing
b) Nurse patient ratio based on shift
supervisors and ward in-charges based on every shift.
c) Assessing Nurse’s competency as per patient’s
Patient assignment is followed wherever possible
condition
NCP.5 The nursing care planned and provided by the nursing professionals is recorded
Document assessment, nursing activities and care
a) Nursing professionals
outcomes in accurate and timely, manner
Senior nursing professionals and nursing supervisors
b) Documented information checked and
should check the information provided by patient are
supervised by nursing professionals
appropriate
A common pattern has to be followed for
c) Uniform pattern for documentation
documentation
Senior nursing professionals and nursing supervisor
d) Supervision for junior staff has to supervise the activities of junior staff and
educate them according to hospital policies.
NCP.6 The nursing care is individual to address the needs of patient and family
Update the protocol on current best practices and it
a) Nursing protocols
has to be updated in nursing manual.
b) ----------------------------
c) Patient care Nursing staff could use specific sensitive
communication and interactive techniques to
 SYNOPSIS FOR NURSING EXCELLENCE

individualize the care

Effective communication for patient requirements
d) Care of patients
among the care providers.
NCP.7 Information is exchanged and documented during each staffing shift, between shift, and
during transfers between units/departments
Documented information should be clearly dated,
timed and signed. Senior staff and nursing supervisor
a) Clear documentation
has to verify whether the needed information are
properly documented or not on daily basis.
The intra - organisation transfers to be done in a safe
b) Transferring patients
manner and the same has to be documented.
NCP.8 There shall be established policies and protocols for vascular access devices (VADs)
a) Policies and protocols for vascular access
Manual to be updated
devices
Nurses shall select the type of catheter based on the
following
1. Prescribed therapy
2. Treatment regimen
b) Catheterization
3. Length of treatment
4. Duration of dwell
5. Vascular integrity
6. Patient preference
c) ---------------------------------
The nurse should handle the catheter as per
d) Usage of catheter manufacture's instructions and senior staff should
monitor.
e) Vascular access bundle care As per CDC guidelines.
NCP.9 The nursing care of inpatients shall be supervised by senior nursing professionals
Guidance by senior nursing professionals which
a) Supervision for junior staff in each shift in each includes Intensive care and high dependency units,
department wards, emergency unit and specialized areas like cath
lab, endoscopy, dialysis, etc.
b) The senior nursing professionals are The senior staff has to update the policies and
 SYNOPSIS FOR NURSING EXCELLENCE

responsibility for the policies and procedures of the protocols as per the latest guidelines and the manuals
respected areas. has to be uploaded once a year.
This shall include supervision and monitoring of all
c) Scope of service for senior staff/ Nursing
nursing activities, quality of nursing care rendered
Supervisor
and turnaround time.
The nursing professionals should ensure all the
reports of the patient are there in their records and it
d) Availability of patient reports
supposed to be checked before the file has given to
Medical records.
The Nursing head and supervisors ensure all the staff
e) Additional knowledge and assistance for nursing
are educated about their policies. The staff should be
staff
educated and evaluated as per the hospital policies.
f) ---------------------------------
g) Evidence based practices
NCP.10 The nursing care of vulnerable patients (elderly, children, physically and/or mentally
challenged) shall be supervised by senior nursing professionals
a) Policy about care of vulnerable patients supposed
to be available in manual and it is responsible for
nursing supervisors and the head of nursing.
b) The training should be given for the staff and the
Protocols and training for care of vulnerable same should be documented.
patients c) As per HCO policy, vulnerable patients are
identified and assessing the patients will done at the
periodic intervals and the same should be
documented.
d) Monitor the patients while contact with the family.
NCP.11 The nursing care of patients under restrains (physical and/or chemical) shall be supervised
by senior nursing professionals.
a) These includes both physical and chemical
measures.
The periodic monitoring done by nursing staff has to
b) Frequently monitoring document the same and it has to be verified by
nursing supervisors.
 SYNOPSIS FOR NURSING EXCELLENCE

Supervisors shall educate the staff on restraint

c) Training and updation for restraint techniques
techniques and implementing innovative techniques.
NCP.12 Appropriate pain management practices shall be supervised by senior nursing professionals
Patients should be screened for pain at the time of
a) Pain management for patients
admission and reassessment of pain is done.
Trained to identify level of pain in various catergories
b) Training for all categories of patient
and document the same.
c) Nursing care for pharmacological and non - It is based on hospital policy and the policy should be
pharmacological there for reference.
d) ------------------------------
The nursing staff should educate the patient and their
e) Educating patients on pain management family members about pain management techniques
in understandable manner and educate the same.
NCP.13 Appropriate end of life care shall be provided to patients needing the same by the nursing
professionals
The nursing professionals should aware about end of
a) Awareness on end of life care policy
life care policy and the policy is available
In this policy, social and spiritual needs of the family
b) Care for end of life care
need to be considered.
c) -------------------------
The staff are trained periodically and document the
d) Training for end of life care
same.
3 - MANAGEMENT OF MEDICATION (MOM)
MOM.1 Indenting of required medication and stores will be done and supervised by nursing staff
made responsible for this function. Storage of medication in the wards and other therapeutic areas
shall be supervised by responsible nursing professionals.
Indent as per HCO policy.
Policy on critically low stocks should be in manual.
a) Medication indenting
Senior nurse in all ward should check and verify the
indents from IPD or Departments.
b) Medication storage  Staff adherence to medication storage
 Cleanliness shall be maintained.
 Vaccines should be kept in refrigerators and
 SYNOPSIS FOR NURSING EXCELLENCE
c) Sound inventory control practices
d) Look - alike and sound - like
e) Storage of emergency medication
f) Availability of Emergency medication
g) Replenishing emergency medicine when used
MOM.2 The dispensing, administration and accounting of medicines shall be carried out by the
concerned personnel and should be appropriately supervised by senior nursing staff
a) Usage of medications
b) Medication labelling
c) Admission for patient
the temperature should be monitored once a day.
 Audits in regular intervals
Nursing professionals should be aware about sound
inventory control practices.
They should be trained and aware of ABC, VED,
FSN FIFO.
Medication shall be stored as per alphabetical or
company’s name.
The list should be documented and the separates racks
sould be there
Update the medication list if required.
A list should be prepared and documented
In Crash cart the medicines should be stored with
labelling . No other drugs shall be kept stored.
Adequate quantity of emergency medicines should be
stocked all the times.
Staff must know when to obtain emergency medicine
while stock outs or if pharmacy is closed.
Inventory check shall be done in daily basis.
Check the medicines once re-sealing
Nursing staff should know about the usage of
medications. Supervisors should educate about
medication usage to prevent medication errors i.e
wrong drug, wrong route, wrong time, etc.
Prior preparations for second drug
Especially for Parenteral drugs, anaesthetic drug
preparation in OTs, antibiotics, chemotherapy and
high risk drugs
Identification of patients with the help of Unique
identification number or name (e.g. hospital number/
IP number/ etc.)
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d) Verification of medication while administration

Following the treatment orders
e) Verification of medication dosage
High risk medication administration should checked
f) Verification of medication route
by two staff and document the same.
g) Verification of medication timing
Monitoring IPD parameters for medication
h) Monitoring for administration of blood and
administration
blood products, chemotherapy and other invasive
Staff should know about if any infrequent medication
procedure
is using in their wards.
After administration all details regarding medication
administration like name of the drug, time and the
i) Recording of medication administration person who is given the drug are documented.
Nursing supervisors should check the records in a
daily basis.
MOM.3 The monitoring of patients after medication administration is supervised by responsible
personnel.
Staff should aware about adverse drug reaction
a) Patients monitoring Senior staff supposed to monitor the junior staff who
is handling the critically ill and post op patients.
b) Patient monitoring after transfusion of blood
and blood products
Educate the staff to monitor the patients and train
c) Monitoring of chemotherapy patient s
them according to the treatment plans and evaluate
d) Monitor post - operative cases or where invasive
procedures are carried out
MOM.4 The nursing professionals must report near misses, medication errors and adverse drug
events as per the policy of the HCO for analysis by the appropriate staff predefined and identified by
the HCO. Feedback is provided to staff which includes the result of analysis and recommended
preventive measures for implementation by the nursing staff wherever appropriate
a) System to capture near miss, medication error
Staff should know about the reporting methods using
and adverse drug reactions including blood
by the hospital
transfusion reactions
These incidents submitted to quality department
b) Reporting shall be done in a specific time frame
within 48 hours from the incident find out.
c) Trained personnel should analyse the incidents Senior nursing professionals or nursing supervisors
 SYNOPSIS FOR NURSING EXCELLENCE

should know about the prevention techniques and

improved monitoring capacity
Nursing professionals should know about the
d) Corrective Preventive actions
feedback mechanism and utilize appropriately.
MOM.5 The organisation shall ensure that it has a policy on verbal orders which will be applicable to
doctors, nursing professionals and technicians uniformly.
a) Addressing verbal orders
b) Policy on who can give verbal orders and how It supposed to have a policy with a yearly updation if
these orders will be validated required and this is applicable for doctors, nurses
c) Approved list of drugs which can be ordered uniformly.
verbally
d) Verbal orders Except emergency or as defined by organisation.
Ratification shall be done at the earliest not later
e) Time frame for verbal orders than 24 hours and the staff should be empowered
about the specified time frame.
4 - EDUCATION COMMUNICATION AND GUIDANCE (ECG)
ECG.1 The organization shall ensure the nursing professionals are trained in communication skills
a) Communication skills training for nursing staff Evaluate them and the same should be documented
The patients should be addressed by staff and it will
b) Bilingual communication
be supported by management.
c) --------------------------------------
It has to be improved periodically and staff need to
d) Improvement in communication skill
be trained in effective manner.
ECG.2 Nursing professionals are aware of their responsibility in protecting patient rights.
a) Patient’s rights The staff should be aware of patient rights at all time
The staff should maintain confidentiality of patients
b) Confidentiality to other. Senior staff should educate the employees
on maintaining patient’s confidentiality.
Female nurses will give care to male patient only if
another female staff or family members are present.
c) Privacy of patients The same holds when a male nursed provides care
for a female patients.
 SYNOPSIS FOR NURSING EXCELLENCE

The staff has to support in patient or family members

Decision making
decision making.
ECG.3 Nursing professionals communicate as ans when required with relevant team members to
achieve continuity of care
Handover forms to be filled when it is done. The
a) Nursing handovers nursing supervisors should check if the handovers
are properly done once a shift gets over
b) Communication to ensure care plans are
----------------------------------------------
implemented
c) ---------------------------------
ECG.4 Patient and family are educated where essential and in case of any change in nursing care
plan
This shall include
Use of medications
a) Patients and family education includes aspects of Food drug interactions
care plan Diet and nutrition
Immunisation
The same should be documented.
Medical condition
Pre and post operative education
Special procedures
b) The education shall cover the following in
Preventive healthcare associated infections
interpretation
When to seek urgent medical attention and home
care. This could be done through booklets / videos/
leaflets.
The staff should explain to patient if any procedures
are performed and the same should be documented
(Consent forms has to get from patient / patient
c) & d) Explanation to patients
attenders if any sugery, anaesthesia administration,
invasive procdures and blood and blood products
transfusions will happen)
Bilingual forms should be there to patient / patient
e)Patients education regarding language
attenders fill the concerned froms.
 SYNOPSIS FOR NURSING EXCELLENCE

5 - INFECTION CONTROL PRACTICES

ICP.1 Infection control nurse (s) shall be designated by the organisation
a) Criteria for designating ICN
b) Training for Infection control
c) Infection control nurse role and responsibilities
ICP.2 Nursing professionals shall adhere to standard precautions and hand hygiene guidelines at all
times.
a) Standard precautions and hand hygiene
b) PPE adherence
c) Auditing regarding standard precautions and
hand hygiene practices
d) Aderence of cleaning, disinfection and
sterilization
e) Safe linen management practices
f) HCO monitor Safe linen management practices
g) Safe injection practices
ICP.3 The nursing professionals shall adherence to handling, storage and disposal of bio medical waste as
per the bio medical waste management Act, 1998.
a) Provision for appropriate Bio medical waste
management practices
There should be one Infection control nurse for every
200 operational beds.
Infection control nurses has to complete a training
cource like Certified professional in Hospital
infection control in advanced level.
It should be documented in their personal files and
the job description should be provided to the
concerns
Infection control nurses should be trained on
standard precautions and hand hygiene and it based
on international / national guidelines.
It should be displayed in every hadn washing area.
It should be available and maintain adequate
inventory in all needed areas.
The audit should be once in every month. The
organisation shall pick the audit tool from WHO’s
hand hygiene observation form and Infection control
assessment tool (ICAT).
This is done through by Infection control assessment
tool (ICAT)
Staff to know awareness and use of PPE and storage
and transportation of used linen.
Infection control assessment tool could be used.
Classes to be conducted for awareness of safe
injection prctices.
Staff should be aware of bio medical waste
management. Bio medical waste management
 SYNOPSIS FOR NURSING EXCELLENCE

committee shall be conducted in regular time period

b) Municipal waste (General waste)
c) Disposal of personal protective equipment
ICP.4 The designated nursing staff perform surveillance activities to capture and monitor infection
control and prevention data.
a) Surveillance activities for high - risk areas and
procedures
b) Hospital associated infection (HAI) rates
c) Surveillance includes monitoring environment
and infection conrtol indicators
d) Surveillance in patient care units
ICP.5 Isolation (barrier and reverse barrier nursing) practices shall be supervised by senior nursing
professionals.
a) Resources for isolation practices
b) Types of isolation
c) Monitoring newly recruited nursing professionals
ICP.6 Infection control nurse maintains records of all occupational injuries and pre - and post -
to discuess and solve issues related to bio medical
waste.
Staff should know the rules and follow that to ensure
the environment safety
Staff should be awared and educated about PPE
disposal.
The surveillance system should be appropriate and
adhering to national / international guidelines and
Infection control assessment tool (ICAT) can be used
for high - risk areas and it can be used for monitoring
isolation precautions, care bundles.
Feedback to be provided to reduce HAI rate
This includes monitoring of SSI, VAP, CLABSI,
CAUTI.
This includes terminal cleaning procedures,
Monitoring efficacy of disinfections.
 Appropriate rooms needed for isolation like
airborne, contact and droplet.
 Proper ventilation needed
 Appropriate signages to be used outside the
room
Staff should know about the type pf isoaltion and its
protocol. A policy should be there for educating the
staff.
Senior staff or nursing supervisors should educate
and monitor how the staff are handling isolated
patients.
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exposure prophylaxis
a) Awareness for staff about hazardous materials
b) Policy and procedure for hazardous materials
c) Spill management
d) Pre and Post exposure prophylaxis
6 - EMPOWERMENT AND GOVERNANCE
EG.1 The responsibilities of those responsibile for nursing management are defined
a) Vision of nursing management
b) Mission of nursing management
c) Nursing department values
d) Organogram of nursing department
EG.2 The Head of the nursing service ensures that suitable mechanisms exist to govern the nursing
service.
a) There is an established head of the nursing
services
b) Nursing manual
c) Policies and procedures
The list of hazardous materials should be
documented and educate the staff to handling ,
storage, labeling etc.
Material safety data sheet (MSDS) should be there in
the required area and staff should be aware of
MSDS.
HAZMAT kit should be available in the required
area and the designated staff should be educated to
use the kit.
E.g Vaccination and needle stick injury should be
documented and needle stick injury should be
administered within the time frame.
Nursing professionals are responsibility for the
nursing management vision and the vision should be
displayed in bilingual language.
Nursing professionals are responsibility for the
nursing management mission and the mission should
be displayed in bilingual language.
The department value should be displayed in
bilingual language.
Hierarchy should be there and it shall be clearly
documented.
They should be recruited based on required
qualification and experience.
Scope of nursing service should be there in nursing
manual and annual ammendment is required when
changes in the scope.
The organisation applicable policies and procedures
 SYNOPSIS FOR NURSING EXCELLENCE
d) Nursing manual
e) Nursing administrative policy and procedure
f) To improve clinical competency
g) Nursing supervisor for quality improvement
programmes
EG.3 Nursing professionals are involved and participate in decision making related to organisation
and nursing services.
a) Nursing management committee
b) Members in committees
c) Nursing professionals providing direct care
d) Feedback mechanism
EG.4 The management empowers nursing staff
a) Nursing empowerment policy
b) Decision making
c) Appraisal and job incentives
d) Education for staff
e) Interpersoal relationships
EG.5 The organisation has an established process for proactive risk assessment and error
management.
a) Error management
is available in the nursing manual.
The nursing department has to follow the policies
and procedures which is written in the manual.
It has to be implemented and followe, Supervised by
nursing incharges.
Nursing manual should help to improve clinical
competency according to hospital policy.
Quality imrpovement programmes should be
conducted and the staff has to be evaluated for
effective work.
Committee has to formed and run the meeting
periodically.
All commitees could have Nursing professionals
appropriate
All should be based on evidence based practices
The feedback forms should be reviewed and
implement the the changes accordingly.
The policy should be educated among the nursing
professionals and evaluate the same to improve
quality of care.
The nursing supervisors trained the employee to take
self decision correctly without supervision.
------------------------------------------------
Staff has to be encouraged to learn how to improve
evidence based practices.
The coordination between staff should be improved.
A clearly defined policy for error prevention, error
reporting and error addressing mechanism.
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Needs adequate materials and equipments and

b) Safe and efficient nursing service
training according to the usage.
c) Patient safety Training to be conducted in patient safety aspects.
Mandatory training could have provided for nursing
d) Training for nursing professionals professionals like Code blue drill, Disaster
management, Fire and Non fire emergencies etc.
e) ----------------------------
Clearly defined process and policy for emergency
f) Escaltion process while emergency escalaition and the same should be educated to
nursing professionals.
EG.6 The infection control programme is supported by the management and includes training of
staff
a) Resources for infection control practices This includes men and materials.
The training should be conducted and the same
b) Induction training for staff
should be documented.
It could be done once a year and the same should be
c) In - service training
documented.
7. NURSING QUALITY INDICATORS
NQI.1 There is a structured quality improvement and continuous monitoring program for nursing
service
It could have represented by a nursing personnel and
a) Quality improvement for nursing professionals there is controlled documentation and the same shall
be updated once a year.
b) Designated personnel for quality improvement The personnel shall be experienced and preferably
programme with exposure to NABH and quality standards.
c) Quality improvement programme It should be reviewed at periodic intervals
NQI.2 The organisation identifies key indicators to monitor the structures, processes and outcomes,
which are used as tools for continual improvement for nursing service.
Patient fall has to be monitored and the same should
a) Patient falls
be documented. Perform RCA when required.
b) Hospital aquired decubitus / pressure ulcer It should be monitored and documented. Perform
c) Medication errors RCA when required.
d) Accidental delining
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e) Extravasation
f) Needle stick injury
g) Restraint related incidents including
strangulation
h) Pain assessment and management It should be monitored and documented
It shall be monitored by senior nursing professionals
i) Patient satisfaction for nursing care
and the same should be documented.
NQI.3 The nursing quality improvement programme is supported by the management
This includes Man, material, machine, money and
a) Resources for quality improvement programme
method.
Nursing department has to coordinate with Quality to
b) Statistical management tool
use the appropriate quality tools.
Using pre determined criteria in consultation with
c) Monitoring nursing satisfaction
Human resource department.
It should be monitored and the same should be
d) Attrition rate and frequency of attrition
documented.
NQI.4 There is an established system for nursing audit
Senior nursing professionals, clinicians,
a) Members for an audit
administrators and core committee members
The parameters has to be clearly defined and ensure
b) Auditing parameters
the parameters met quality in our organisation
Make confidentialiy and the designation should be
c) Patient and staff anonymity is maintained used for the person participate in the audit instead of
names.
All should be documented and reviewed. A checklist
d) Review of audit rexords
has to be formed.

e) Implementation after review Find improvement for the Non compliance and it
could be improved by root cause analysis.
NQI.5 Incidents, complaints and feedback from nursing professionals are collected and analysed to
ensure continual quality improvement.
a) Incident reporting It should be documented and reviewed.
b) Feedback and complaints The organisation has to communicate to patient
 SYNOPSIS FOR NURSING EXCELLENCE
c) Analysis of incidents
d) Corrective and Preventive action (CAPA)
e) Feedback about care and service
about the feedback system and complaints through
brouchers or displaying.
Quality committee is responsible for this and
analysis will done through Root cause analysis.
All the actions should be documented and use quality
tools to find corrective preventive action.
It shall be communicated on a monthly basis.