nursing department: administrative sop 1. 2. 3. excellence/7327/self assessment... · nursing...

FORTIS HEALTHCARE LIMITED

NURSING

Administration

Nursing Department: Administrative SOP

NSG/ADM/1.0

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1. Vision

Saving and enriching lives

2. Mission

To offer a patient-centric, distinctive health care environment where patients and caregivers

are treated with compassion and respect while providing safe, evidence-based, nursing

services.

3. Fortis Nursing Values

Patient Centricity: Treat patients and their caregivers with compassion, care, and

understanding in all nursing tasks and duties.

Ownership: Be responsible and take pride in all actions

Integrity: Demonstrate moral courage to speak up, be honest, principled and always

do the right things.

Innovation: Continuously improve and strive to exceed expectations.

Teamwork: Respect, value and proactively support all co-workers and operate as

one team.

4. Objectives

Treating patient and his family/significant others as one inseparable unit

Upholding the rights of patient and family

Actively participating in the patient/family care planning

Gaining and giving co-operation to all the other departments

Seeking ways for continuous improvement through on going education, training and

certification

Sharing and upholding the vision of the organization

Giving and earning trust in our interpersonal relationships

Imparting health teaching to patients and their family/significant others to ensure

speedy recovery and maintenance of health.


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5. Scope of Services

The nursing department provides round the clock services in the following departments

I. Departments:

Emergency Room (ER): - Includes Triage in all hospitals and High Dependency Unit (HDU) in

some of the hospitals. Nurse patient ratio is 1:2.

Triage: All patients coming to ER are assessed and sorted for first aid, stabilization and

admission or stabilization and discharge

High Dependency Unit (HDU): - This unit caters to all critically ill patients requiring close

monitoring and constant observation and nursing care without artificial ventilation. High

dependency Unit has a nurse patient ratio of 1:3

Intensive Care Units: Intensive Care Units consists of monitored intensive care beds where

in all critically ill or postoperative cases are taken care of. The nurse patient ratio here is

1:1.25 –2. The units are equipped with bedside monitors, central monitoring system, facility

for invasive and non-invasive ventilation and other invasive monitoring facilities. The name

of the ICU can vary from unit to unit depending on the patient population that it caters to.

Some of the common specialty ICUs is as follows –

Cardiac Surgical Intensive Care Unit/Surgical Intensive Care Unit (CSICU/SICU) - All Cardio

Thoracic Vascular Surgery (CTVS) post-op patients are taken care till the day they are fit to

be transferred back to patient rooms. Some critically ill pre-op patients are also admitted to

this unit.

In hospital where no separate CSICU, other specialty cases TKR, THR, Craniotomy) and

surgical patients who require critical monitoring and ventilatory support are also admitted

to the unit.

Pediatric Intensive Care Unit (PICU) –

This is the pediatric ICU who require critical monitoring, ventilator support are admitted

Coronary Care Unit (CCU) - All critically ill cardiac patients are admitted here. All post PTCA,

post PPI, Post EPS, RFA, non-surgical closure of ASD & VSD & post ICD implantation patients

are also kept here in the immediate post-procedure period. The stay varies from few hours

to 1-2 days. In units where separate CCU is not present, patients are admitted in either SICU

or MICU.


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Medical Intensive Care Unit (MICU) - This unit caters to non surgical all critically ill patients.

Wards - The wards consist of single rooms, twin and triple sharing and ward rooms. The

nurse patient ratio here is 1:6 or 1:7

Operation Theaters - Consists of all operation theaters according to specialty. Multispecialty

Operation Theater services include Eye, ENT, General surgery Gynecology, Plastic Surgery,

Gen. Surgery Dental and Urology. In units specializing in Neuro, Ortho, and Cardiac,

surgeries specific OTs and /or time slots are demarcated unless the hospital has special OTs

for these specialties. The nurse table ratio is 2:1

Cardiac Operation Theater (COT) – In units with dedicated cardiac OT, all types of cardio-

thoracic surgeries are done. Commonly done surgeries are CABG, MVR, AVR, DVR,

Correction of TOF, ASD & VSD, and Repair of Aortic Aneurysms. Thoracic and vascular

surgeries are infrequently undertaken

Renal Operation Theater (ROT) - In units with dedicated ROT all types of renal surgeries are

undertaken.

Ortho Operation Theater (OOT) - In units with dedicated Ortho OT all types of ortho

surgeries are undertaken including joint replacements.

Catheterization Laboratory (Cath Lab) - All invasive cardiac procedures are done here. The

procedures done here include: CAG, PTCA, TPI, IABP insertion, PPI, EPS, RFA, IVC Filter, ASD

& VSD closure & ICD implantation.

Out Patient Department (OPD) - Here all in-house and empanelled consults have slots for

their consultation. The nursing here supports Non-Invasive Cardiology, Radiology, Nuclear

Medicine, Diabetic Clinic & Blood Bank also. Nurses here render assistance to the

consultants in way of taking vital signs and assisting in OPD Procedures.

Dialysis Unit - The Dialysis Unit runs in two/ three shifts and all outpatient and in-patient

dialysis is undertaken here. Portable dialysis units are used for bedside dialysis of critically ill

admitted patients.

II. Services cover the following areas:

Patient Assessment

Patient admissions in all units take place through Triage in emergency cases and during

nonworking hours/holidays and through OPDs during working hours.


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All beds are kept ready for the patient’s admission at all times. Beds are allocated by IPD in

consultation with the respective unit in charges. As soon as the patient arrives, initial

assessment is done by the assigned nurse, by checking the documents, collecting relevant

history and doing a quick physical examination.

The patient needs are identified, and necessary medical/nursing orders are carried out. The

patient and significant others are given orientation to the ward, patient protocols are

explained.

All the investigative/therapeutic and nursing procedures are explained to the patient and

significant others. All the necessary and relevant patient education is carried out by the

designated nurse or the nurse patient educator (if the unit has one)

The types and ages of patients served

Patients of all age group are admitted to the units. Patient acuity ranges from completely

dependent patients in ICUs to partially dependent patients in the wards.

The extent to which the level of care/ service provided meets customer needs

The nursing department caters to meet cent percent nursing needs of the clients. The

recommended staffing is maintained round the clock. To improve the efficiency levels of the

staff; continuing education programs are planned and carried out by the Nursing Education.

Appropriateness, clinical necessity, timeliness of support service provided

The Nursing Department maintains the intensity of service provided 24X 7 in all units except

in OPD’s which are closed during non-working hours/holidays. On call services are provided

by Dialysis nurses in nonworking hours/ holidays.

III. Interdepartmental communication

Nursing maintains Interdepartmental communication with the following departments-

F & B (Food and Beverages)

Diet for patients is always requested by the Nurse

Appropriate therapeutic diet is planned by dietician after nutritional assessment.

Appropriate intimation is provided by the Nurse to dietetics department when a diet

is changed or when there is a patient transfer/discharge.


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Engineering & Bio Medical Department

The Charge Nurse sends the request for maintenance & repairs to these

departments as soon as the need is identified.

The nurses share joint responsibility for handling /care of biomedical equipments

and other fixtures in the patient care areas

The Nursing team works in conjunction with Engineering and Bio Medical to ensure

timely check and preventive maintenance of all equipments and fixtures is done.

Biomedical and Engineering department is called periodically for training needs of

nurses about biomedical equipments training by the nursing education as and when

required.

Laundry

Nurses liaises with Laundry for all linen requirement as per the hospital protocol

House Keeping

Nurses are supported by House Keeping to ensure a clean and safe environment in all areas

as per set hospital standards.

Inpatient Department (IPD)

Does accurate & timely co-ordination with IPD on transfers, admission, discharges &

deaths

Filling up of billing activity (as per set guidelines of the hospital)

Clearance for procedures & surgeries are obtained from IPD desk

Discharge clearance is obtained from IPD before physically allowing the patient to

leave the hospital.

Stores

Indent all consumables, drugs and stationery from the stores.

Buffer stock given in the units is the responsibility of nurses and they facilitate audits

as and when required

Return unused drugs and consumable

Central Sterile Supply Department (CSSD)

CSSD supports nurses by supplying all sterile items for the units.


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Items are either taken as stock or loaned from CSSD.

Nurses are responsible for ensuring proper storage and count of all CSSD items.

Radiology

Send requests through HIS appropriately

Take appointments before sending patients for ultrasound/CT/Carotid Studies

Inform once again before sending the patient for a test

Get someone ready to pick patient after investigation

X-ray films not reported to be sent soon after the doctor has seen them

Knowledge of necessary preparations for radiological procedures

Laboratory

Tests to be done should be indicated clearly in the forms and entered appropriately

in the system (Modified)

Check samples before sending for any clotted/inadequate sample etc.

Ask for the reports through HIS of tests done and inform doctor immediately after

receiving reports

Inform in advance to Lab person for collecting samples for biopsies/Mxt test

Write clearly the type of fluid/tip of lines/type of catheter when sending for cultures

Blood Bank / Blood storage

Give pre-information regarding blood demand

Send appropriate requests through system and double check on phone

Proper labeling – only stickers

Send samples of grouping and cross matching without delay

Know the protocol for blood returns in case of reaction

Send appropriate forms after administration of blood safely

Take consents for HIV tests.

Medical Records Department (MRD)

Completion of discharge/death files as per hospital standards

Dispatching files to MRD after ensuring proper arrangement of patient record)

Handling MLC files


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Information Technology (IT)

Support for Hospital Information System (HIS) and for Hardware

Human Resources (HR)

HR coordinates the recruitment of nurses.

Nursing works in close coordination with HR is respect to: Attendance, leave, service

bonds; monthly performance allowance, medical insurance, remunerations and staff

welfare.

6. Nursing Manpower planning

Nursing Manpower planning is done every year taking into consideration the following

I. The business growth plan of the unit

New Medical Programs

New Departments

New Services

II. The current manpower deployment versus the nursing norms

III. The projected Occupancy for the year to come

Nursing Norms

Fortis Nursing Norms are derived from various sources such as guidelines laid down by

NABH staffing guidelines, Indian Society of Critical Care Medicine guidelines for staffing of

critical care units.

S.No Department Manning Norms

1 Wards Ratio 1:6

2 Ots 2 nurses per OT in M and E shift, 3 nurses in the night

3 Cath Lab 2 nurses per Lab per shift

4 ICUs/Emergency/BMT/Transplant Ratio 1:1.25 -2

5 Labor Room 2 nurses per table per shift

6 Pediatric Ward Ratio of 1:2

7 OPDs 2 nurses per shift for POD of 25

8 Blood Bank 1(No Reliever)


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9 Clinical Instructor 1 per hundred nurses

10 Nurse educator 1(No Reliever)

11

Day Care

(IVF/Endoscopy/Urology/Cath

Recovery) Ratio 1:3

12 Infection Control Nurse 1 per hundred nurses

13 Nurse In Charges 1 per nurse station (No Reliever)

14 Supervisor I per 100 beds per shift or one per shift

15 DCNO 1 (No Reliever)

16 CNO 1 (No Reliever)

Staffing plan

The staffing is done based on occupancy and the required staffing ratios are maintained

round the clock through redeployment of staff in each shift by the shift-nursing supervisor

as and when required. Please Refer Acuity tool in Annexure I

Monthly Duty Roster

Purpose

To maintain required nurse patient ratios.

To ensure equal distribution of shifts to all staffs.

Each staff will get one weekly off every week. (Sunday – Sunday must reflect one off).

Every shift must have a proper mix of staff to ensure the required quality of care.

After long leave all the staff will be assigned to morning shift or evening shift only

Compensatory off will be given only if the supervisor justifies the extra duty Attendance

should reflect these accurately. After night duty an off is compulsory. None can come on

morning or evening. Nurse In charges to ensure that hard copies of duty rosters are

submitted to the Nursing office before the first of the next month after duly uploading it

into the system

Contingency Plan


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Purpose

To ensure sufficient manpower in the areas with deficient staff

Floater policy

Shift supervisors are responsible to float in and out of nurses in order to ensure all areas are

adequately staffed in quantity and quality. Unit In-charge/shift in-charge must send the staff

without delay to the directed Units.

The nurse who comes for help must introduce herself/himself to the Unit In charge/Shift in

charge.

The In charge will assign patients as per the capabilities and needs.

A brief orientation as to where to find what will be given by the In charge.

Medications will be always administered under supervision.

In charges will ensure that the nurse who is floated into his/her unit is relieved for the tea

and lunch breaks

In charges to ensure that the nurses are relieved at the end of the shift in a timely manner.

Calling off duty nurses

In time of acute surge in patient load, shift supervisor maintains Nurse patient ratio by

calling in nurses living locally or those living in staff hostel provided for by the hospital.

At times nurses continuing into the next shift due to sudden staff shortage caused by

unplanned leave are provided for with food and appropriate time back. This is done at the

discretion of the shift supervisor

Leave Policy

Purpose : To ensure effective utilization of staff to ensure safe nursing care.

Annual leave plan is made for a period of 12 months (April to March)

Annual leave plan will be submitted to Nursing Office in the first week of January.

The in-charge needs to start working on plan well in advance in conjunction with the

concerned ANS/supervisor, so that the leave plan permits only the no. of staffs that

could be on planned leave at one point of time.

The staffs who do no avail the leave as planned are not guaranteed annual leave at

another time of their convenience.


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Leave plans once approved by NS/CNOs cannot be changed unless the NS/CNOs

approves it again.

Any extension of planned leave without a valid reason will be treated as leave

without pay.

Public holidays can be clubbed with planned leaves and the same must be

mentioned in the leave form as suffixed or prefixed.

Nurses availing planned leave must report to the nursing office before proceeding

for leave and on resuming duty.

All CL/SL etc. must be submitted for approval within 48 hrs of resuming duty;

otherwise they shall be treated as absent.

The responsibility of submitting leave application in time lies exclusively with the

employee

Ward In-charge, supervisor to oversee and ensure its adherence.

All In-charges will confer with area ANS/supervisor; for granting unplanned leaves

and get approval from HOD.

Casual Leaves, when a particular department is light, can be given only after

consulting ANS/Supervisor/HOD to ensure no staffing issues in other areas

Sick leave must be informed minimum 2 hours before starting of duty. The staff

when sick must report to OPD/ER as per the hospital protocol

Any leave for more than 2 days will need to be informed to HOD for approval


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DEPARTMENTAL STRUCTURE (ORGANOGARM)

KEY RESPONSIBILITIES: Chief Nursing Officer

Title: Chief Nursing Officer /Nursing Superintendent

Nos: One

Qualifications: MSc / BSc / Diploma in Nursing Administration

Experience: Minimum of 2 years of experience as NS OR 3-5 Yrs as ANS

Reporting: Reports to Facility Director/ Medical Superintendent

Shift Timings: General Shift

Principal Duties and responsibilities:

Formation of nursing service Philosophy

CNO/NS

ANS/Supervisor

Nsg Services

ANS/Supervisor

Nsg Education

Clinical

Instructors

Unit In-Charge

Shift In-charge (Sr. Staff

Nurse)

ANS/Supervisor

Nsg Services

Patient

Educators

Staff Nurse

DCNO/DNS


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Formation of aims, objectives and policies of nursing services

Interviewing nurses

Prepares Budget for nursing service department.

Evaluate confidential reports and recommends staff for promotion.

Functions as a member of condemnation board for linen and equipments

Enforces implementation of hospital policies.

Investigates complaints and takes necessary steps.

Maintains discipline among nursing staff.

KEY RESPONSIBILITIES: DEPUTY NURSING OFFICER

Title: DEPUTY NURSING OFFICER

Nos: One

Qualifications: MSc / BSc / Diploma in Nursing Administration

Experience: Minimum of 2 years of experience as DNS OR 3-5 Yrs as ANS

Reporting: Reports to Nursing Superintendent



Assumes Nursing Superintendent’s responsibilities in her/his absence.

Key responsible areas will be assistance to all functions of CNO.

Any other additional responsibilities as designated by CNO.

KEY RESPONSIBILITIES: Assistant Nursing Superintendent

Title: Assistant Nursing Superintendent

Nos: As per hospital strength

Qualifications: B.Sc. / GNM / Diploma in nursing administration

Experience: 2 years experience on the similar position OR 3 Yrs as ANS

Reporting: Chief Nursing Officer



Assists in selection/requirement of nursing staff.


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Assists in planning and organizing the new units of hospital

Keeps records and reports of nursing services.

Helps in allocating nursing personnel to various nursing service department

Maintains confidential report and records of nursing staff of his/her area.

Participates in unit based quality management/ care improvement programs.

Organizes and plans nursing care activities of the department according to hospital

policies and service needs.

Coordinates and promotes relationship between nursing staff and other

departments.

Enforces and monitors adherence to standards of practice according to hospital

rules, regulations and policies.

Submits specific performance information for staff evaluation to Chief Nursing

Officer

KEY RESPONSIBILITIES: NURSING SHIFT SUPERVISOR

Title: Nursing Supervisor

Nos: As per areas

Qualifications: BSc / GNM

Experience: Minimum of 3 – 5 years of experience as a unit in-charge


Shift Timings: All three Shifts


Give complete and comprehensive report to the incoming supervisor and to NS as

per set guidelines

Arranges staffing as per need for the next shift and does changes during the shift

depending on workload in various units

Analyze and evaluate future staffing needs

Guides unit in-charge in planning and scheduling of work for nursing personnel &

GDA’s ensuring proper distribution of assignments and adequate manning


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Maintain liaison between nursing personnel and other departments to ensure

coordination for optimal patient care

Counsel unit in-charges, staff nurses in the development of professional skills

Maintain communication with patients, the families and other hospital staff to

ensure compliance with hospital administrative and nursing policies

Prepares and submits reports to NS/ANS as directed

Responds to all code blues and ensures patient care as per guidelines

Responds to emergency situation and resolves issues in consultation with

NS/ANS/MD as required

Responds to patient/family/staff grievances and addresses them in professional

manner upholding the organizational values

KEY RESPONSIBILITIES: CHARGE NURSE

Title: Charge Nurse

Nos: One per each unit

Qualifications: BSc /GNM

Experience: Minimum of 3 years of teaching / clinical experience




Prepares monthly duty roster, leave plans and Unit reports

Responsible for raising flag for requirement of Nursing buffer and reviewing patient

acuity in ICUs and other areas

Calculating and reviewing productivity metrics e.g. Nurse per occupied bed ratio etc.

Responsible for quality metrics and patient care metrics

Responsible for Supervision and implementation of efficient nursing care of

inpatients

Responsible for orienting new Joinees to the Unit and ensures completion of unit

orientation and finishes the check list


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Maintains the record of mandatory tests and in service attendance. Ensures filling of

nursing documents as per protocols

Conduct morning rounds of the unit. Take a account of any problem and resolve it.

Keep the ward stock replenished and ensure all items are accounted for.

Ensures upkeep of equipment of respective unit and promptly inform the Bio-Med/

Engineering department for repair of any defects in the equipments.

Attend monthly meetings and disseminates information to the rest of the team

members.

Should be present at the time of handover and make sure that patient assignments

are carried out appropriately.

Should inform hospital acquired infection, untoward treatment outcomes to the

infection control nurse.

Able to identify potential falls, pressure ulcers and guide staff accordingly

Ensures patient safety at all times from admission till discharge

Maintain departmental policies and able to intervene when not in compliance

Documents all incidents in record for reference for annual evaluations.

Discuss with patient / family any issue related to care.

Demonstrates effective management.

Able to manage and improvise in case of short supplies

Maintains confidentiality and record of the staff

Able to resolve staff complaints and ensures staff satisfaction.

KEY RESPONSIBILITIES: NURSE EDUCATOR

Title: Nurse Educator

Nos: One

Qualifications: MSc / BSc

Experience: Minimum of 5 years of teaching and 3 years of clinical exp.

Reporting: Nursing Superintendent



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Plans coordinate and conducts formal nursing induction program.

Makes monthly In-service Education Calendar and Induction Program details and

send it to all nursing and other concerned departments

Plans coordinate and conduct variety of in-service education program.

Modify and update existing educational programs when appropriate.

Impart continuing education through mini workshops, re-demonstration of skills &

mini quiz etc.

Assist in making nursing protocols, modify and update the existing protocols

Maintain liaison with training department in planning seminars, workshops,

educational programs and related activities

Keep records and reports of all trainings and send the monthly report for the same

to the HOD

Help the HOD for planning, organizing and conducting nursing certification programs

Keeps abreast of new developments in training techniques, methods and programs

Liaise with other departments in planning, seminars, workshops and other related

activities

Assist in preparing budget for teaching and training aids

Contribute in nursing and medical research endeavors

Productive member of Nursing Quality Improvement Committee and a member of

any other committees as directed by superiors.

KEY RESPONSIBILITIES: CLINICAL INSTRUCTOR

Title: Clinical Instructor

Nos: One per 100 nurses

Qualifications: M.Sc./BSc

Experience: Minimum of 2 years of teaching / clinical experience

Reporting: Nurse Educator




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Facilitator in the induction program & ensure that all staff of her unit have

undergone induction.

Assess & identify any learning need of staff in her area & then plan with Nursing

Educator to organize & execute retraining for them.

Assists Nursing Educator in making protocols, care plans & audit checklists.

Gives incidental teachings on rounds & demonstrate skills whenever appropriate.

Conducts code blue drills.

Keeps a record of in-service attendance of staff & motivate those with less

attendance.

Assists Nursing Educator in conducting practical exams for trainees.

Coordinates with Dr’s for in-service classes

Executes training programs for nurses.

KEY RESPONSIBILITIES: PATIENT EDUCATOR

Title: Patient Educator


Qualifications: M.Sc./BSc

Experience: Minimum of 2 years of clinical experience

Reporting: Nursing Educator



Visit all patients at different times of the day.

Ensure pre-op & post-op to all patients

Give incidental teaching to patients, their relatives as appropriate during rounds

Present lectures and trainings to a group or individuals as appropriate

Prepare educational material for clients as appropriate in consultation with the

specialists

Evaluate programs as and when required

Take return demonstration from clients

Involve/educate staff nurses on health education as and when required


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Document all health educations given

Liaise between clients and medical team for any clarification/educational needs of

any clients

KEY RESPONSIBILITIES: INFECTION CONTROL NURSE

Title: Infection Control Nurse


Qualifications: GNM/BSc





Daily visits to all wards and patient holding units.

Collection and tabulation of daily data of all incidents of hospital acquired

infections

Collection of needle stick injury incidents and assisting Infection control team in PPE

Ensuring that samples of blood, stool, sputum, urine, swab, when indicated are

collected and dispatched to the laboratory on time.

Initiating hospital infection control form while documenting for nosocomial

infections.

Computation of ward wise or procedure wise statistics

Daily visit of laboratory to ascertain results of previous days’ sample

Warning treating doctor on any positive cultures

Monitoring and supervision of infection control practices among hospital staff.

Training of nurses and paramedical personnel on Infection Control policies and hand

hygiene

Conducting educational activities related to infection control practices for

housekeeping and nursing aids.

Assist in bacteriological studies of all cases.

Conducting infection control quiz.


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KEY RESPONSIBILITIES: QUALITY NURSE

Title: Quality Nurse


Qualifications: MSc/BSc





Conducts incident, investigations including root cause "near miss "and sentinel

event.

Performs Core Measure abstraction and data analysis, prepares reports for Chief

Nursing Officer, Quality Assurance Department and Accreditation Bodies.

Assists the Chief Nursing Officer and Quality Head in developing and/reviewing

forms used for medical records, ensuring compliance with all regulatory agencies

and accreditation bodies and/or policies, protocols and standards

Provides information, training, guidance and support for ensuring quality and

adherence to accreditation standards in the nursing team

Acts as staff and/or participating member of various committees; participates in

Nursing and Physician staff meetings for information gathering and consultation

KEY RESPONSIBILITIES: GENERAL NURSE

Title: General Nurse



Experience: Minimum of 1 year of clinical experience

Reporting: Charge Nurse/Area ANS

Shift Timings: All three shifts


Compliance of nursing manuals/protocols at all circumstances while on duty


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Following medical prescriptions/orders and taking care of patient’s need

Taking care of minimum housekeeping standards including related departmental

interface.

Complete hand over/take over of her assigned patients including physically checking

patients and their units.

Checks her special assignments like checking of crash cart, checking inventory, or any

other assignment given by in-charge

Plans, organizes, and delivers nursing care in a manner that upholds organizational

values, healing, promotion of health and prevention of complications

Maintenance of nursing records including nurse’s notes, charts, consents, and initial

assessment data for all assigned patients as per protocols.

Maintains continuity of care through clear and concise verbal and written

communication with all departments, internal and external customers

Reception and orientation of newly admitted patients assigned to him/her.

Collects and sends all relevant documents duly completed to ensure speedy

transfers or discharge process. Will accompany all critical & helpless patients.

Performs nursing procedures as per set protocols in the department

Imparts relevant health education to patients and families and documents of the

same.

Takes care of all dying patients, maintains seriousness and accompanies every dead

body to the mortuary.

Attends all in-service education programs and takes mandatory certification

programs.

Takes responsibility and accountability in professional advancement.

Specific Responsibilities towards Geriatric Patients:

Should understand psychological changes and emotional needs of an elderly.

Should be able to do assessment of all systems and must have knowledge of

physiological changes when aging.

Should be able to understand and provide safety and security needs to the aged.


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Should be able to explain events and procedures in concise, simple and

understandable language.

Be able to reduce anxiety and agitation

Must be a patient listener

Be able to promote independence in self-care activities.

Should be able to assess intake and urination patterns and should be able to provide

appropriate clothing to facilitate toileting.

Specific Responsibilities towards Pediatric Patients:

Should use skills that eliminates or minimize the psychological and physical distress

experienced by children and families.

Must make parents aware of all available health services, information of treatments

and procedures and encourage changing or support existing health care practices.

Be able to identify growth and development needs as per age of the child

Be aware of safety measures to be adopted for children during treatment in hospital.

Restorative role, which includes restoration of health through care giving activities.

Coordination/collaboration with member of health team

KEY RESPONSIBILITIES: CARDIAC OT NURSE

Title: COT



Experience: Minimum of 1 year experience in Operating room

Reporting: Area ANS Charge Nurse

Shift Timings: All Shifts


Takes complete hand over of patients received in OT or any patient in post-op area

Checks her assigned OT for complete carbolization and readiness for surgery

Ensures that the OT is uncluttered and clean at all times

Ensures that all surgical specimens are sent as per protocol.


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Accompanies consultants/SR on rounds.

Ensures that information regarding any issues including wrong count is of primary

concern and should inform the OT in charge without delay.

Informs in charge without any delay in supplies that are about to finish to help in the

smooth running of the unit.

Informs in charge of any breakage, faulty equipment etc: without delay

Returns all unused medications/consumables to stores before sending the billing

activity.

Ensures timely and accurate entries in BA (manual and HIS) at all times.

Informs any requests for leave duties to in charge in writing before the 20th of every

month

Checks all documentation (nurses note, charts, consents, patient data) for its

completeness

Maintains continuity through clear and concise verbal and written communication

with all departments, internal and external customers

Assists in transfer of post op patients in a safe and efficient manner. Follows

guidelines laid in protocols


transfers or discharge process. Will accompany all critical & helpless patients


Imparts relevant health education to patients and families and documents the same


programs

Plans, organizes, sets up surgical trolley, anticipates needs of surgeon and performs

surgical counts, disposal of waste as per protocol

Always behaves in a manner of upholding organizational values, promoting health

and preventing complications

Floats as a helper to other areas as and when directed by superiors

KEY RESPONSIBILITIES: MULTISPECIALITY OT NURSE


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Title: MSOT


Qualifications: GNM/Bsc

Experience: Minimum of 1 year experience in Operating room


Shift Timings: All Shifts

Principal duties and responsibilities:

Takes complete hand over of patients received in OT or any patient in post-op area

Checks her assigned OT for complete carbolization and readiness for surgery

Ensures that the OT is uncluttered and clean at all times

Ensures that all surgical specimens are sent as per the protocol.

Accompanies consultants/SR on rounds.

Ensures that information regarding any issues including wrong count is of primary

concern and informs the OT in charge without delay.

Informs in charge without any delay in supplies that are about to finish to help in the


Informs in charge of any breakage, faulty equipment etc: without delay.


activity.



month


completeness



Assists in transfer of post op patients in a safe and efficient manner. Follows



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same


programs



Always behaves in a manner of upholding organizational values, promoting health

and preventing complications


KEY RESPONSIBILITIES: ICU NURSE

Title: Intensive care unit



Experience: Minimum of 1 year experience in ICU


Shift Timings: All Shift


Maintenance of nursing records including nurse’s flow sheet, charts, consents, and

initial assessment data for all assigned patients as per protocols.

Maintains continuity of care through clear and concise verbal and written

communication with all departments, internal and external customers

Reception and orientation of newly admitted patients assigned to him/her.


transfers or discharge process. Will accompany all critical & helpless patients.



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same.


programs.

Takes responsibility and accountability in professional advancement.

Updates herself in special skills from time to time.

Educates herself on any new equipment installed in her unit.

KEY RESPONSIBILITIES: CATH LAB NURSE

Title: Cath. Lab



Experience: Minimum of 1 year experience in Cath. Lab


Shift Timings: All shifts


Takes complete hand over of patients received in Cath Lab

Checks her special assignments like checking of crash cart, taking inventory, or any

other assignment given by in-charge

Checks assigned Cath lab for complete carbolization and readiness for procedure

Ensures that the Cath Lab is uncluttered and clean at all times

Ensures that all samples are sent as per protocol.

Assists consultants/SR during procedures as per protocol

Ensures that information regarding any issues is informed to unit in charge without

delay.

Informs In charge of any delay in supplies that are about to finish to help in the


Informs in charge of any breakage, faulty equipment etc: without delay.


activity.


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month


completeness



Assists in transfer of post procedure patients in a safe and efficient manner. Follows





Imparts relevant health education to patients and families and documents the same


programs



Always behaves in a manner upholding organizational values, promoting health and

preventing complications


KEY RESPONSIBILITIES: Chemotherapy Nurse

Title: Chemotherapy Nurse

Nos: As per bed strength


Experience: Minimum of 1 year experience in Oncology

Reporting: Deputy Chief Nursing Officer/Area ANS

Shift Timings: Morning/ Evening/General


Assumes responsibility for the complete management of oncology patients


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Function as an interface between patients, Oncologists, staff nurses and others

involved in patient management.

Designs and maintains chemotherapy patient records which enhance

communication and continuity of care.

Designs orientation tools/programs for nurses in management of oncology patients,

in consultation with NS oncologists and hospital management.

Actively participates in empowering the staff with knowledge and skill in oncology

nursing by conducting lectures, discussion and demonstration.

Responsible for providing guidance and counseling to the staff in their dealing with

oncology patients.

Assures overall responsibility of indenting, storage and safe administration

chemotherapy agents.

Responsible for providing relevant education and counseling to oncology

patients/family members.

Identifies areas that require staff development initiatives in the delivery of nursing

care of oncology patients.

Collaborates with other departments in development of orientation activities in the

management of oncology patients.

Promotes nursing research by initiating and participating in different programs.

Monitor and evaluate cost effective and safe nursing practices, recommending and

implementing changes as required.

Collects, complies and disseminate statistics of oncology patients.

7. On Boarding of New Joiners

Objectives

To familiarize a new nurse with

Various departments of the hospital

The unit he/she will be working

Organizational policies and protocols

The line of communication


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Soft Skills

Expected professional behavior

Operation of Equipment

Computer Training

Induction program is planned every month & is scheduled in the In-service Calendar

It consists of

Theory sessions -12 days

Unit Orientation -15 days

On the job training involves working with a Mentor .The nurse may be assigned

responsibilities under supervision – 30- 60 days

After being granted privileges the staff is assigned independent responsibilities - 90 days

Competency Assessment – after 6 months

Nursing Induction Program

This induction program is intended to structure the transition of novice nurse to competent

nursing professional

Purpose:

To provide basic orientation to novice staff nurse about Hospital physical structure,

organogram, SOPs etc.

To provide Skill based training to improve area specific competency

To develop soft skills through Service excellence training

To provide training about Hospital Information Service

Nursing Induction Program includes

Classroom Induction Training: HR Induction, Nursing classroom Induction

Service Excellence Training

On The Job Training

Classroom Induction Training:

Every new joined nurse undergo classroom induction training which are conducted

by Human Resource (HR) Department and Nursing Department


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HR Induction: It is conducted by HR team as well as respective team members such

as Infection Control Nurse (ICN), Safety Officer and Quality Officer Etc. It is 16 hours

program followed by the written test.

It focuses on:

Orientation to Fortis Healthcare

Organogram of complete Hospital

Scope of Services provided in the Hospital

Facility Round

Employee Rights and Responsibilities

Duty Timings, Leave management through Software

Process of obtaining Salary Slip, Income Tax related formalities

Medical benefits available to Nurse and family

Employee Vaccination

Performance Appraisal

Grievance policy

Prevention of Sexual Harassment Policy

Disciplinary measures

Safety Codes and preparedness including Fire Safety

Hospital Infection Control and Biomedical Waste Management

Basic Life Support

Quality Indicators, Service Indicators, NABH Accreditation

Incident Reporting process

Care of Vulnerable patients

Organizational Initiatives such as Sparkle

Nursing classroom Induction

It is conducted by Nurse Educator, Charge Nurses, ICN and senior staff nurses. It is 11 days

program, that include following topics

Organogram of Nursing Department

Rules and regulations about Nursing Hostel


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Important Contact Numbers

Uniform policy, Grooming

Duty Rota, Assignment books

Patient Identification

Nurse Patient Communication, Nursing Care Bundle

Medication Safety : Safe drug Administration, High Alert Drugs, LASA Drugs,

Concentrated Electrolytes, Narcotics policy and Drug Calculations

Practical Training of Drug administration

Patient Safety: IPSG Goals

Fall prevention

Restraint policy

Prevention of Hospital Acquired Pressure Ulcer

Nursing processes such as : Admission, Discharge, Transfer

Initial Nursing Assessment and Reassessment

Patient’s Medical Records Documentation

Safe use of common biomedical equipments

Hospital Information System: Drug Indent, Diagnostic Test entry, Electronic Patient

Record Checking, etc.

Pharmacy processes

Imaging processes

Laboratory Investigation processes

Code Blue Policy and CPR Training

Skill Based Training : IV Cannulation and Safe Infusion Practices

Sample Collection for Culture test

Nursing procedures such as: Vital Signs monitoring, Nasogastric Tube Insertion and

Nasogastric Feeding, Nebulization, Steam Inhalation, 12 lead ECG

Preoperative care and Post-operative care

Prompt answering of call bells

Importance of various Inventory books. Daily Billing Activity


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Addressing Patient Concern and feedback, prompt escalation of concerns

These trainings are followed by written test


This training is conducted by Nurse Educator as well as HR team members. It Focuses on

Nurse patient interaction

On The Job Training (OJT)

This is an area specific structured plan for novice nurse to develop competencies.

It is based on SOP of the unit, specific Nursing skills, documentation etc that needs to

be developed.

It is conducted by Charge Nurses and Senior Staff Nurses/clinical instructors.

Duration is One month but it may need to be prolong depends on competencies

developed by the respective novice nurse.

Here the novice nurse starts working in the assigned department according to the

privileging. The necessary hands on training and assistance are provided by Charge

Nurse and senior staff nurse.

The Nurse Educator monitors the progress of On the Job Training. Competency test

is conducted at the end of six months. The Charge Nurse provides feedback to staff

nurse.

555 Checklist is a structured regular follow up checklist used by Chief Nursing Officer

to interact with new nurse about their experience in the hospital, hostel and

induction activities

8. Performance Standards (for new joiners)

Purpose

To ensure that all new nurses are inducted and assessed via common tools for assurance of

minimum entry level competence.

Policy:


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The new nurse will be under probation for 6 months. During this time she/he is expected to

complete all requirements as listed in the table below in order to be eligible for

confirmation.

S. No Elements Time Frame Resp.

1 Find it yourself Checklist 2 Days After joining Unit I/C

2 Unit Orientation –New Staff

15 days to 45 days (Depending on

stipulated period as fixed by the

unit)

Unit/CI

3 Induction Record 14 Days (During Induction) NE

4 Induction Checklists 90 Days CI/Unit I/C

5 Assignment Record 60 Days CI

6 Competency Assessment 1 month, 5 Months CI/Unit I/C

8 Pass Infection Control Test

(> 60%) 90 Days Self

9 Pass Nsg. Protocol Test (>

60%) 90 Days

Self

9. Monthly Performance Assessment (NQIP)

Purpose

To ensure that standards of nursing are maintained.

Policy

The Monthly Performance Assessment, based on observed behavior/conduct of the

employee.

The following principles would govern the administration of Monthly Performance

Assessment

The team members would be judged on the following criteria:

Late comings/Early goings

Grooming

Conduct


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Customer Orientation

Absenteeism

Late comings

The team members would be expected to be on their work place in time.

Time discipline would be noted for each team member.

Absenteeism

Regular attendance, no leave without pay, leaves planning in advance and with sufficient

notice would be encouraged.

Customer Orientation

The issues related to patient care, attitude of team members towards the patient,

responsiveness, proactive ness, complaint redressal would be looked into.

Conduct and Discipline

The general conduct, including team play, towards superiors, peers, other departments,

record maintenance, quality of work, imbibing and display of organizational values and

culture etc would be taken into account under this head.

Grooming

This would take into account the dress, attire and grooming. Team members are expected

to adhere to all points given in grooming standards as prescribed including maintenance and

wearing of neat and clean uniform, shoes, hairdos as prescribed (shaving for males),

jewellery as prescribed, body odor etc

The area in charge would be required to keep a record of each of these criteria. The

following would be the format for recording the data for each team member.

S.No Criteria 1 2 3 4 Remarks

1 Late coming

2 Absenteeism

3 Grooming

4 Customer Orientation

5 Conduct

The scoring is to be done as given below:


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a. Late comings

No late coming would earn 4 points

One-two late comings would earn 3 points.

Three-Four would get 2 points

Five or more than five would get 1 point.

b. Absenteeism

No absenteeism would earn 4 points.

Even one day less (Without pay/ absent without intimation) would earn just 1 point.

c. Grooming

If no aberration is noted as per grooming/uniform policy (already in place), there

would be four points.

1 incident – 3 points, 2 incidents – 2 points & more than 2 incidents just 1 point

d. Customer Orientation

If no adverse incidents related to patient care are reported, there would be 4 points.

1 incident – 3 points, 2 incidents – 2 points & more than 2 incidents just 1 point.

e. General Conduct

Similarly, for conduct, if no adverse incident is recorded, there would be 4 points,

one incident-3 points, two incidents-2 points and more than two incidents-just 1

point. The maximum possible score (MPS) would be 20. The area in charge would be

required to be very judicious in rating and must record specific instances on a daily

basis. In the remark column, the incidents would require to be recorded

10. In-Service Education

This program is intend to update the knowledge and practices of nursing professionals

Purpose

To provide trainings based on training need analysis

To ensure all nursing team members are updated with reviewed SOPs

To ensure adequate nursing team members are trained to provide (ACLS) Advanced

Cardiac Life Support


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To ensure adequate nursing team members are trained to provide Pediatric

Advanced Life Support (PALS) and Neonatal Resuscitation

To provide training on Safe and effective use when any new biomedical equipment

is introduced

To provide Skill based training when any new product is introduced such as IV

cannula etc.

To provide guidelines before implementing any new medical record document or

change in format

To reorient the nurse about knowledge and practice when change of department

and change of responsibility is done

Continuous Nursing Education Program includes-

Daily afternoon class

Area Specific Training


Orientation Training for Change of Department

Orientation Training for Change of Responsibility

Daily afternoon class

Daily class is for all evening shift nursing team

Training Calendar is rolled out at the beginning of the month

These classes include topics based on training need analysis and mandatory training

topics

Training of staffs done when new equipment are introduced in the system

Area Specific Training

It focuses on specific nursing procedures carried out in the unit

It also focuses on type of nursing care provided in the respective unit

As per training need analysis , if any one unit has certain training needs accordingly

focused sessions are conducted

It is driven by charge nurse



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The modules are:

Patient First

LEAP

Corporate grooming

Telequettes

Email Etiquettes

Orientation Training for Change of Department

The Nurse who is posted to a new department undergoes On the Job Training for

his/her new department

Orientation Training for Change of Responsibility

For up gradation/change of responsibilities:

The nurse will undergo training module that include the necessary domain

knowledge, skill development, clinical experience from the respective expertise

The concerned immediate supervisor will assess the competencies and if necessary

further training needs will be provided

Training Need Analysis

This ensures review of patient care provided by nursing team and there training needs. It

also provide the structure for Corrective and preventive actions for incidents that occur due

to training deficiencies

Responsibility: Nurse Educator, Charge Nurses and Chief of Nursing

Purpose:

To identify specific training needs of nursing team

To incorporate nursing outcomes in the continuous nursing education program

To divide training topics as per need such as training for entire team and trainings to

specific units

Nurse Educator takes account of following aspects while analyzing training needs

Patient’s feedback


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Consultant feedback that indicate training needs of nurses

Staff score in the monthly performance assessment (NQIP) done by their immediate

supervisor

Incidents such as medication errors, patient’s fall, and hospital acquired pressure

ulcer etc.

Incidents of Hospital Acquired Infection

Process and Outcome Audits such as Medical Records Audit, Audits conducted by

Infection Control Nurse (ICN), Clinical Pharmacist etc.

Observations of mock drills of safety codes and Code Blue

Reports of SOP Compliance audit

Introduction of any new practice/ software for Patient care or Employee Service

Competency Assessment tests and Quarterly test score

Structured Training Need Feedback from Charge Nurse (Please refer Annexure II)

Effectiveness Check

Training is validated through skill verification and subsequent certification as

applicable or evaluator tests

Training certificates and skill verification practical re-demonstration on the job

11. Nursing Empowerment

Chief Nursing Officer is the driving force for nursing Empowerment. Every Nurse is

empowered to take decisions about patient safety and recovery. Doctors and other

departmental personnel are always approachable and follow teamwork approach. Nurses

are empowered to inform patient’s condition to Consultants directly.

Early Warning Score Assessment, Safety codes are placed to handle medical emergencies

like cardiac arrest and stroke. Innovation is encouraged by nurses to improve patient care

and safety, quality, process improvement and service timeline. Nurse driven quality

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are members of all important hospital committees. Planning of training calendar is done

with active involvement of nurses.

Structured program exists for enhancing clinical competency and leadership skills of nursing

professionals; as knowledge is the basic requirement to exercise empowerment of the team

12. Shift Handover/Endorsement

Purpose: To ensure continuity of care

A structured shift hand over is done among assigned nurses in the units also

amongst shift supervisors

Shift hand over communication is based on communication guideline of SBAR (

Situation, Background, Assessment, Record)

It is documented at every shift change and signed off by both duty staff nurses

Shift handover involve active participation of patient, whenever possible

Charge Nurse or senior staff nurse monitors the complete shift handover is carried

out and essential information is handed over effectively.

Formats of Endorsement guideline and documentation can be referred in Annexure

III and IV.

13. Nursing Audits

Objective

To ensure that our clients get care with the accepted International standards

Nursing Audits are conducted to evaluate the services provided to our clients. The results of

these audits are then compared with the accepted standard checklists that we have.

Training and re-audits are done if required to ensure that the care provided by our nurses

meet the client’s need and according to the established standards. Following are a few of

the audits-

Infection Control Audits

Nursing Process compliance audit

Nursing Care Bundle audit


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HAPU prevalence audit

Patient and Unit Safety audit

Medication safety audit

Crash cart audit

Nursing Quality and Patient Safety

We believe that quality improvement is an on-going process and as the front line deliverers

of patient care, we have a major and responsible role to play in improving and maintaining

quality care to patients and families.

We also believe that improving and maintaining quality of nursing personnel is equally

important to achieve the above.

We believe that constant efforts to work hard in hand with other services to achieve the

above are equally crucial and all efforts will be made to achieve the organizational goals.

Goal

Nursing Quality Improvement Committee (NQIC) aims to ensure that a constant process is

undertaken so that all the patients and families leave Fortis with a positive experience and

to prepare nurses adequately for the said role based on regular monitoring, auditing,

counseling and evaluation.

Objectives

Develop nursing sensitive quality indicators

Develop tools to measure the outcomes

Evaluate monthly and plan and implement corrective actions

NQIC would also be responsible to meet with staff who have low performance levels,

attitude problems etc. For this purpose only the HOD, ANS/Supervisor and

concerned unit in-charge will meet the staff for counseling session.

The counseling session would be documented in the staff diary with the signatures

of all members.

NQIC meeting is part of monthly unit in-charges meeting. ANS / Sr. Nsg Supervisor to

ensure presence of deputed members as indicated


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The NQIC will concentrate initially on the frequently detected problem areas in the

department.

NQIC will gradually work toward establishing indicators and establishing

methodologies at par with international hospitals.

NQIC will be responsible for educating all nursing staff on the quality improvement

activities.

NQIC will educate unit in-charges to initiate their own quality improvement activities

in their respective areas.

NQIC will ensure active participation in the Quality improvement program of the

hospital.

NQI committee will consist of

Chairperson: Chief Nursing Officer

Coordinator: Deputy Chief Nursing Officer

Members (Permanent): All unit Charge Nurses

Members: Deputed staff (3)

NURSING QUALITY INDICATORS

The following quality indicators are adopted by department of nursing as per guideline laid

by international Nursing bodies

1. Pressure Ulcers:

The incidence of pressure ulcers would be less than 4 among all ICU patients. The measure

would be computed as:

Number of patient with Hospital Acquired Pressure Sore X 1000

Total no. of patient days

The incidence of pressure ulcers would be 0% in all other patients.

All patients received with pressure ulcer from outside will exhibit improvement in the level

of their ulcer.

2. Patient Falls

The rate per 1000 patient days at which patients experience an unplanned descent to the

floor during the course of their hospital stay. The measure would be computed as


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Total No. of patient Falls X 1000

Total no. of patient days

3. Patient Satisfaction with Pain Management

A measure of patient perception of the hospital experience related to satisfaction with pain

management.

Definition: Patient’s opinion of how well nursing staff managed their pain as determined by

scaled responses to a uniform series of question designed to elect patient views regarding

specific aspects of pain management. The questions would be administered to a sample of

all patients admitted to the hospital. All surgeries requiring more than 3 days of hospital

stay.

4. Patient Satisfaction with Educational Information:

A measure of patient perception of the hospital experience related to satisfaction with

patient education.

Definition: Patient opinion of nursing staff efforts to educate their regarding their

conditions and care requirements as determined by scaled responses to a uniform series of

questions designed to elicit patient views regarding specific aspects of patient education

activities. The questions would be administered to a sample of all patients admitted to the

hospital for acute care services. Necessitating more than 3 days of hospital stay.

Patient Satisfaction with Nursing Care

A measure of patient perception of the hospital experience related to satisfaction with

nursing care.

Definition: Patient opinion of care received from nursing staff during the hospital stay as

determined by scaled responses to a uniform series of questions designed to elicit patient

views regarding satisfaction with key elements of nursing care services. The questions would

be administered to a sample of all patients admitted to the hospital for acute care services.

Hospital Acquired Infection:

List of Hospital Acquired Infection and measure to calculate rates are:

CLABSI: Central Line Associated Blood Stream Infection

No. of CLABSI X 100

Number of central line days


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CAUTI: Catheter Associated Urinary Tract Infection

No. of CAUTI X 100

Number of catheter days

VAP: Ventilator Associated Pneumonia

Number of ventilator daysX 100

Number of Patient Days

SSI: Surgical Site Infection

Number of SSI cases X 100

Total number of surgeries

NSI: Needle Stick Injury, Sharp Injury

Number of incidents of exposure to blood & body fluids reportedX 100

Number of patient days

Hand Hygiene Compliance:

Total number of acts of hand hygiene when the opportunity existed X 100

Total number of hand hygiene opportunities

5. Nurse Staff Satisfaction

Job satisfaction expressed by nurses working in hospital settings as determined by scaled

responses to a uniform series of questions designed to elicit nursing staff attitudes toward

specific aspects of their employment situations. The questions would be administered to all

RNs in direct patient care or middle management roles at the institution.

14.Nursing Patient Safety Goals

Goal: Improve the accuracy of patient identification.

Use at least two patient identifiers (neither to be the patient’s room number) whenever

administering medication or blood products; taking blood samples and other specimens for

clinical testing, or providing any other treatments or procedures.

Goal: Improve the effectiveness of communication among caregivers.


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For verbal or telephone orders or for telephonic reporting of critical test results, verify the

complete order or test result by having the person receiving the order or test result “read

back” the complete order or test result.

Standardize a list of abbreviations, acronyms and symbols that are not to be used

throughout the organization.

Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and

the timeliness of receipt by the responsible licensed caregiver, of critical test results and

values

Goal: Improve the safety of using medications.

Remove concentrated electrolytes (including, but not limited to, potassium chloride,

potassium phosphate, sodium chloride>0.9%) from patient care units.

Standardize and limit the number of drug concentrations available in the organization.

Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the

organization, and take action to prevent errors involving the interchange of these drugs.

Encourage reporting of all medication errors and complete analysis of errors where

indicated

Goal: Improve the safety of using infusion pumps.

Ensure free-flow protection on all general-use and PCA (patient controlled analgesia)

intravenous infusion pumps used in the organization.

Goal: Reduce the risk of health care-associated infections.

Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene

guidelines.

Manage as sentinel events all identified cases of unanticipated death or major permanent

loss of function associated with a health care-associated infection.

Goal: Accurately and completely reconcile medications across the continuum of care.

Current medications upon the patient’s admission to the organization and with the

involvement of the patient. This process includes a comparison of the medications the

organization provides to those on the list.


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A complete list of the patient’s medications is communicated to the next provider of service

when it refers or transfers a patient to another setting, service, practitioner or level of care

within or outside the organization.

Goal: Reduce the risk of patient harm resulting from falls.

Assess and periodically reassess each patient’s risk for falling, including the potential risk

associated with the patient’s medication regimen, and take action to address any identified

risks.

FALL PREVENTION

PREAMBLE:

While it could be argued that all patients are at some degree of risk of falling during

hospitalization, some patient characteristics have been identified as being associated with

increased risk of falling. These include age, mental status, a history of falling, medications

impaired, special toileting needs and some medical diagnosis.

PURPOSE:

To achieve and maintain 0% fall incidents in the hospital

FALL PREVENTION INTERVENTIONS

ASSESSMENT

All patients will be assessed at the time of admission for risk of falling, receiving transfers

The “PTF” (potential to fall) precaution will be maintained throughout hospitalization except

those who have been put in the category for being in ICU’s. However universal fall

precautions will be continued for ALL PATIENTS

EDUCATION

Educational activities will be part of the fall prevention program and will be as follows:

Staff training to increase awareness of high-risk patients and prevention strategies

All nurses will be familiarized with the fall prevention program and evaluated

through a test and have to score equal to or more than 60%.

Educating the patient and family about the risk of falling, safety issues and their

mobility limitations. The same will be documented in patient records.

Teaching patients to make position changes slowly.

Orienting all patients to their bed area, ward facilities and how to get assistance.


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Explaining the use of grab bars in toilets to all patients

Reinforcing education to all high risk patients on a regular basis (every shift) and on

transfer between two wards

ENVIRONMENTAL ISSUES

Activities that aim to reduce environmental risks include:

Decreasing obstacles and clutter

Night-lights at bedside and toilet

Stabilizing beds and bed side furniture

Having grab bars near toilets

All repairs to be attended without delay

ELIMINATIONS

Interventions to support the patient’s elimination needs include:

Placing patients with urgency near toilets

Checking patients who are receiving laxatives and diuretics

Toileting at risk patients routinely (offering bed pan and urinal at regular intervals)

Instructing male patients prone to dizziness to sit while urinating

If need to stand, ensure someone is there with the patient

MEDICATIONS

Activities related to medication include:

Receiving prescribed medications along with doctor

Checking patients receiving laxatives, diuretics, antihypertensive etc.

Limiting combination of medications when possible (eg: sedatives, analgesics etc.)

MOBILITY

Interventions related to mobility:

Non-skid footwear

Providing physiotherapy

Instructing patients to rise slowly

Assistance while walking for “PTF” patients

Repeating activity limitation instruction to patient and family


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Assisting “PTF” patients during transfer

Assisting “PTF” patients to increase mobility by walking patients in corridor once or

three per shift if there is no medical contraindication.

MENTAL STATE

Altered mental status is one of the common identified risk factor for fall and the

intervention includes:

Reorienting confused patients

Orienting patients to the hospital environment

Moving confused patients near nurse’s station

Using family members to sit with confused patients

BED REST

Interventions that aim to reduce the risk of falling while patient is in then bed include:

Ensure bed is in “Low” position

Ensure bed brakes are on

Ensure bed side rails are in “UP” position

Ensure patients can reach necessary items

WHEEL CHAIRS & CHAIRS

To prevent fall involving wheel chairs include:

Use safety straps or seat belts in chairs

Ensure support to prevent slipping from chairs

Selecting suitable chairs for sitting and ensure appropriate height for transfer

MISCELLANEOUS

Use “PTF” stickers or charts

Seek help from physical therapy

Involve family in care

Warning all staff concerned on “PTF” status

Reassuring staffing needs in relation to high risk patients

All patients will be nursed under universal fall precautions.

All patients are considered to carry a risk of fall during hospitalization


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General Interventions are:

The beds will be always maintained at a “LOW” position except for procedures

needing higher heights of bed

N.B: When the need is over, the nurse must ensure that the bed is returned back to

“Low” position.

All the side rails must be in “UP” position all the time.

The assigned nurse will ensure that the call bell is within reach at all the times. The

return demonstration from patient will be takes on admission and on transfer

The patient and family will be oriented to the needs of keeping the side rails “UP”

The bedside of the patient will be maintained uncluttered at all times by the

assigned nurse

The foot stool will be placed at the right place to facilitate patient’s getting down

from bed

The brakes of beds, wheel chair and trolleys will always be kept locked

All patients will be visited hrly by the assigned nurse

The high-risk patients will be identified as per the assessment tool (Nursing

Admission/Assessment Form)

All critically ill patients are automatically placed under the category (PTF: Potential to

Fall). If the score is less than 7 the counseling will be documented in the approved

format by the doctor on duty and witnessed by the assigned nurse. (Fall risk

counseling form)

One Attendant will be allowed with the patient at all times except in the critical care

areas.

Assessment potential to fall will be noted prominently in the care records.

In assessment PTF will be noted in the daily worksheets of all units.

The patient and family will be educated especially as the preventive measures and

the same documented in the nurses notes.

If patient or family insists in violating the precautions the same will be documented

in the medical records


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The patient with “PTF” identified will not be allowed to move out of bed without

supervision of a nurse.

These patients will never be left alone in the toilets, even if the patient insists to be

left alone.

All “PTF” patients will be transferred only if the attendant is present.

All “PTF” patients will be especially checked before settling at night:

Check the side rails are “UP” position

Check the breaks of bed are locked

Check the call bell is working and within reach

Check if the patient/family knows how to use the call bell

Ensure all required items are in place

Reinforce need to call nurse for any requirements during night especially;

elimination

EVALUATION OF FALL PREVENTION INTERVENTIONS

Monitor and record all patient falls

Evaluate the situation that led to fall and suggest changes

Implement changes and modifications to the program in response to evaluations\

15.STATUTORY OBLIGATIONS

CONSUMER’S PROTECTION ACT - Implication on Nursing Practice

Consumers of health care are increasingly demanding to have a say in matters affecting

their health care. As consumers have become more aware of their rights, conflicts between

patients, health care professionals and institutions have developed. Nursing is affected by

this kind of situation in which nurses are also expected to answer questions, explain

procedures and respect the rights and requests of the patient. Nurses are challenged to

become advocates for clients.

The Consumer Protection Act enacted by the Parliament in 1986, has been drastically

amended and its scope greatly widened by the amendment of 1993. The Act now covers all

kind of services an all kinds of consumer transactions whether made in cash or in kind. It


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protects the consumer form the burden of restrictive and unfair trade practices and enables

the consumer forums and commissions to award compensation not only for monetary loss

in purchasing defective material or in hiring deficient services but also for mental pain,

suffering and harassment caused by defective goods or services. Services rendered by

hospitals & members of medical profession for consideration constitutes as defined in the

Act. Deficiency in medical services gives the patient as a consumer the right to claim

compensation, (Poonam Verma vs Ashwin Patel (1996) 4SCC332.)

Nursing as a professional and nurses as an individual have long been advocating for the

welfare of their patients. The impact of health care consumer movement has been to

promote increased accountability on the part of all health professionals including nurses.

Today’s nurse practitioners must be aware of nursing standards, legal issues in nursing, legal

limits of nursing and legal liabilities otherwise he/she will be the first person to be penalized

from the legal standpoint.

Special legal concerns in professional Nursing practices:

Service areas of nursing practices are particularly fraught with legal risk.

Crime: Violation of any law governing the practice of any licensed professional may be

prosecuted as a crime even if no actual harm occurs to the patient e.g. giving medication

without physician’s prescription. Torts are a civil wrong committed against a person & may

be either intentional or unintentional. Physical, emotional, economical harm may also result

in tort. Negligence is the failure to act as a reasonably prudent person e.g. any nurse who

does not meet accepted standard of care or who perform duties in careless fashion runs a

risk of being found negligent. Reighton (1975) identifies some of the common acts of

negligence.

Negligence: fall of a patient from bed, failure to communicate charges in client’s condition,

use of defective apparatus; abandonment; infection due to lack of aseptic techniques; loss

or damage to client’s property; burns from hot water bottle, heating pads, enema, douches

& baths; overlooked sponges in operative procedures; error in identification of patient

including babies.

Malpractices: is the negligence on part of a health care professional Malpractice occurs

when a professional fails to act as a reasonably prudent professional under specific


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circumstances that leads to harm or injury to patients. For example at bed time the nurse

fails to put protective side rails on the bed of elderly disoriented patient and patient falls

from the bed sustaining injuries; other examples are the nurse fails to carry out medical

orders, the nurse abandon a patient needing care; nurse fails to make an accurate

assessment of patient and act on assessment

Assault and Battery: Assault is the threat or an attempt to make bodily contact with other

person without consent. Battery is unconsented or unlawful touching of a parson e.g. a

nurse threats a patient who doesn’t eat meal, the patient may assault her in return giving

the patient an injection against his/her will even on a physician’s prescription is battery.

Patients have the right to refuse treatment even if the treatment would be in the best

interest.

Informed Consent: All patients should be given an opportunity to grant informed consent

prior to treatment. Nursing also must obtain consent for nursing measures to be

undertaken. Nurses can witness patient’s signing of informed consent documents but are

not responsible for explaining the proposed treatment nor are they responsible for

evaluating whether the physician has truly explained the significant risk, benefits and

alternative treatment.

Invasion of Privacy: A claim of invasion of privacy also may be brought against a nurse e.g. if

client has a V.D., the nurse should not disclose the information except if directly relates to

care and Rx. A nurse’s unwanted intrusion in private family matters is another example of

invasion of privacy.

False Imprisonment: Making a person stay in a place against his/her wishes is false

imprisonment.

Defamation of Character: Any communication that injures and individual’s reputation and is

disclosed by another person is considered libel (written) or slander (oral). For example if a

nurse tells a client that his physician is incompetent, he/she could be hold liable for slander.

The nurse who writes such a comment could be sued for libel.

Preventing Legal Problems In Nursing Practice: Legal responsibilities in nursing practice are

becoming of greater importance day by day. But many nurses view the law with

apprehension because they fear being named in a malpractice law suit. With increased


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emphasize on client’s rights nurses today must understand their legal obligations and

responsibilities towards clients. Nurses who give competent care based on their education

will seldom need to worry about a malpractice lawsuit. There are a number of effective

strategies that professional nurses can use to limit the possibility of legal action.

Practice In Safe Setting: in order to be truly safe nurse must be committed to safe patient

care. The safest situation is one in which agency employ an appropriate number and quality

of patients; procedures and personal practice that promote quality improvement; keep

equipments in good condition; provide orientation to new employees; supervise all level of

employees.

Communicate With Other Health Professionals: The professional nurse must have open

and clear communication with nurses, physician and other health care professionals. No

matter how good the nursing is if the nurse fails to maintain clinical records, in the eyes of

the law the care did not take place.

Meet The Standard Of Care: The single most important protective strategy for the nurse is

to be a knowledgeable and safe practitioner of nursing and to meet the standard of care

with all patients. Meeting the standard of care involves being technically competent,

keeping up to date with nursing standard of care, boundaries within which nurse practice. If

a nurse does not perform duties within accepted standard of care they may place

themselves in jeopardy of legal action. Indian Nursing Council Act’s give authority to the

council to maintain standard in the field of nursing education and practice of health care

innovations. TNAI is another source of uplifting standard of nursing care. International code

for nurses is subscribed by TNAI.

Promote Positive Inter Personal Relationship: Even in the face of untoward outcomes from

health care providers, it s usually the unhappy patient that sues. Therefore, the best

strategy for the professional nurse is prevention of legal action through positive inter

patient relationships with patient and team members.

Legal issues confronting practicing nurses today are many but the nurse should view the law

not with apprehension but as a helpful adjunct to define nursing practice.

INDIAN NURSING COUNCIL ACT 1947:


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The Indian Nursing Council, which is the statutory body, came into being through Act that

was passed through the Indian Parliament in 1947, which regulates the nursing education

and practice in the country.

The Indian Nursing Council functions through the State Councils who is responsible for

registration of nurses who have successfully completed and attained entry-level

qualification in nursing. (Baccalaureate program in Nursing for 4 years and Diploma in

Nursing and Midwifery for 3 and half years) It is the function of the council to declare that

such qualification is a legally recognized qualification for the purpose of this act.

However the Act does not have any provision for regulating nursing practice in the states. It

also does not have any system of national examination for nurses’ registration to ensure

standards of nursing education and practice. Neither does it offer any guidelines for

continuing education and systematic ongoing competency assessment for continuation of

nursing licensure.

The Nurses working in different states also need to register with the State Nursing Council.

The state nursing council issues permanent or temporary registration to nurses practicing

within areas under its jurisdiction as per its policies.

16.Management of Information

PURPOSE:

To ensure complete and accurate flow of information in the department to all the nurses.

PROCEDURE:

NS holds nursing departmental meeting every month within 5 days of Hospital

Monthly Review meeting.

NS, ANSs, Supervisors, In-charges and shift in-charges attend the meeting.

Minutes of the meeting are recorded and circulated.

Following Departmental Meeting, every unit is expected to have unit meetings for

dissemination of information and plan of actions decided in the departmental

meeting.

This meeting is also a forum for discussing issues of staff and other related issues.

The minutes of the meeting is sent to NS, and ANS via E-mail or hard copy.


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Area ANS are required to conduct a meeting with their in-charges and form agenda

to be discussed in the monthly meeting.

Apart from the above scheduled meetings HOD can call for emergency meetings of

short duration to tackle emergent issues.

General body meeting will be held once in 3 months.

S. No Report Frequency Purpose

1. NQIP Report Monthly to be

submitted to HOD by

20th by respective Unit

In-charges

To ensure all nurses meet that set

standards. To encourage good

workers.

To facilitate corrective actions for

those who have problems.

2. Evaluations 6 Months after joining

and then yearly

As per mentioned in the section

“Evaluations”

3. Incident Reports As and when required This is for information to higher

authorities and for further action to

prevent such incidents.

4. Attendance Record Monthly Submitted by unit in-charge with

hours worked by each staff in their

unit.

5. Monthly

Departmental

Meeting

Monthly Minutes of the meeting held

monthly with unit in-charges,

supervisors, ANS & NS along with

NQIC members.

6. Unit In-charges

Monthly Report

Monthly Minutes of the unit meeting held

after departmental meeting for

dissemination of information and

discussion for quality improvement

activities.

7 Unit In-Service Minimum once in a Attendance record submitted by


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Attendance Record month unit in-charges for in-service

conducted in the unit.

8 Unit Statistics Monthly Submitted by unit in-charges in the

approved format at the end of every

month.

9. Daily Report Daily Submitted by shift supervisor for

the purpose of census.

10 Daily Nursing report Daily Submitted by Unit In-charges to

report daily activities

11 ER statistics Daily ER census

12 Incident reports Monthly To collect data of any untoward

incidents

13 Infection Control

Statistics

Monthly To ensure compliance to infection

control measures.


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16. List of Forms filled by Nurses in Medical records of the patient 1. Nursing Admission Assessment Form with Plan of care: Specific to Adult,

Maternity, Pediatric, Neonate and Emergency room

2. Valuables Handover Form

3. Daily Nursing Flow Sheet : Intake Output Chart, Risk assessment Scores, Care

Summary, Nurses Notes and Plan of care

4. Vital Signs Chart

5. Glucose monitoring Sheet

6. Physician Order Chart for Drug administration Record only

7. Patient and Family Education Record

8. Investigations Chart

9. Radiology Requisition slip

10. Laboratory Requisition Form

11. Endorsement Sheet

12. Pre-Operative Checklist

13. Surgical Safety Checklist (Specific Fields)

14. Recovery Room Chart

15. Blood Transfusion Record

16. ICU Vital Signs Flow Sheet

17. Restraint Form: Care and Assessment only

18. IABP Chart ( as applicable in ICU)

19. Transfer Out Summary (Specific Fields)

20. Transfer Out Checklist

21. Intra partum monitoring (For Labor room)

17. Patient absconding from hospital

PURPOSE

To ensure that all patients admitted under our care are safely discharged from the hospital

after improvement in health.

POLICY

Every patient admitted under our care is discharged from the hospital on his recovery

PROCEDURE

Nurses will meet all their patients whenever a shift is changed


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If a patient is not found in his room/Bed/Toilet, (unless otherwise taken for

investigation/Procedure/ Physiotherapy etc.) the assigned nurse will raise an alarm

and inform the Nursing Supervisor/Charge Nurse/Security Supervisor/IPD/MS. The

IPD personnel will call for the patient’s relative through PA system in the waiting

lobby

If there is no one available, the search for the patient and his relative will begin in

the hospital

If not traceable within the Hospital premises, the nurse will call at their home

address and inform them about the missing patient

Once confirmed that the patient is not traceable, the nurse will inform Security

Supervisor who will inform the police

If no information from patient from security, as per instruction of MS the nurse will

start system discharge process of patient and close the nurses notes

EQUIPMENT

Telephones.

Nurse’s notes.

DOCUMENTATION

The nurse will record all events accurately and completely in her nurse’s notes and will close

the notes once it is confirmed that the police is informed by the security

PREVENTIVE MEASURES:

All patients must be in prescribed uniform with ID band till the time of discharge


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SOP NSG/ADM/1.0

Version : 1.0 Prepared by: CNO, Nurse Educator ,DCNO

Effective from: 01/April/2016 Reviewed by : Roselind Mathews (Regional Nursing Head)

Review date: 31/March/2017 Approved by: Michael Moorhead (National Nursing Head)