The checklist is designed to assist health organizations or hospitals with the significant

standards necessary to deliver quality nursing service to our clients. The clinical service
component focuses on defining what the standards are in the clinical setting. ANSAP Standard
(2008)
STANDARD OF NURSING SERVICE; CLINICAL SERVICE COMPONENT
STANDARDS
MEASURABLE ELEMENTS
I.
STANDARDS ON ASSESSMENT OF CARE
Standard I:
a. Provision of complete nursing
Assessment
assessment within 1st 24 hours of
Process
admission for inpatient client
b. Provision of complete nursing
assessment within 1st 2 hours of
consultation of an outpatient client
c. Evidence of patients reassessment
throughout the nursing care process
c.1 presence of vital sign monitoring
sheet
Standard II:
1. Presence of well-defined policy or tools
Assessment
on nursing assessment in terms of scope
Scope and
and content which include but are not
Content
limited on the following:
a. Physical Assessment
a.1Neurological Assessment
a.2Cardiovascular Assessment
a.3Respiratory Assessment
a.4 Gastrointestinal Assessment
a.5 Genitourinary Assessment
a.6 Musculoskeletal Assessment
a.7 Integumentary Assessment
a.8 Sensory Assessment
b. Social Concerns
c. Spiritual Concern
d. Economic Factor
e. Health History
e.1Developmental History
e.2 Family History
e.3 Medications taken
e.4 Allergies
f. Vital Signs
g. Pain Assessment
h. Nutritional Status, Needs and Risks
i. Discharge Plan

Yes

No

Remarks

2. Criteria according to patients functional

capacity and needs like:
a. Nutritional and Metabolic Patterns
b. Elimination Pattern
c. Activity and Exercise Pattern
d. Sleep and rest pattern
e. Sexuality and Reproductive Pattern
f. Sensory and Perceptual Pattern
g. Cognitive Pattern
h. Role and relationship Pattern
i. Self-Concept pattern
j. Coping and stress tolerance Pattern
3. Other pertinent data
4. Nursing assessments are documented on
patients record

II.
III.

IV.
V.

VI.

Standards on Assessment of Care

Standard I: Assessment process
Standard II: Assessment Scope and Content
Standards on Care of Patient
Standard I: Care Process
Standard II: Care Plan
Standard III: Implementation of care
Standard IV: Evaluation of Care
Standard V: Pain Management
Standard VI: Medication Management
Standard VII: End-of-Life Care
Standard VIII: Patient and Family Rights
Standards on patient and Family Education
Standard I: Education Assessment
Standard II: Education Plan and Programs
Standards on Access and Continuity of Care
Standard I: Access to care
Standard II: Emergency Patients
Standard III: Admitted Patients or In-Patients
Standard IV: Intensive and Specialized Services
Standard V: Continuity of Care
Standard VI: Discharge, Out on Pass, Referral and Follow-up
Standard VII: Transfer of Patient
Standards on Nursing Documentation
Standard I: Structural Data

Standard II: Clinical Data

STANDARDS ON NURSING SERVICE: ADMINISTRATION AND
MANAGEMENT
I.
Standards on Governance and Direction
Standard I: Governance and Structure
Standard II: Governance Responsibility and Accountability
Standard III: Direction-Setting
Standard IV: Strategic and Operational Plans
Standard V: Financial Plan and Resource Allocation
Standard VI: Policies and Procedures Development
Standard VII: Ethico-Moral and Legal Accountabilities
Standard VIII: Professional and Organizational Involvement
II.
Standards on Human Resource Management
Standard I: Administrator of Nursing Services
Standard II: Staffing Plan
Standard III: Recruitment, Selection, Hiring and Appointment
Standard IV: Credentialing
Standard V: Staff Placement
Standard VI: Staff Job Description
Standard VII: Staff Development
III.
Standards on Facility Management and Environment Safety
Standard I: Facility Planning
Standard II: Environmental Safety
Standard III: Staff Education
IV.
Standards on Quality Improvement
Standard I: Leadership and Staff Education
Standard II: Quality Programs
Standard III: Quality Monitoring, Analysis and Implementation

The checklist is designed to assist health organizations or hospitals with the significant
standards necessary to deliver quality nursing service to our clients. To achieve this, standards on
nursing is designed with two components; Clinical and Administration& Management. The
checklist below deals with the second component which is administration and management. This
concerns managing the nursing services in the hospital. There are five (5) identified standard by
ANSAP Standard (2008).

STANDARDS

MEASURABLE ELEMENTS

I.
STANDARDS ON GOVERNANCE AND DIRECTION
Standard I:
A. Displayed organizational chart that
Governance and
shows:
A.1 functional relationship
Structure
A.2 positional relationship
A.3 Span of Control
B. Governance structure of Nursing
Services is described in written
documents with the approval of proper
authority
C. Nursing Service governance structure
depicts decentralization or unit-based
decision making
D. Nursing Services governance structure
and processes support professional
communication
D.1 downward communication
(memo, policy/orders, posting notices,
staff meeting)
D.2 upward communication
(duty request letter, excuse letter,
employee suggestion boxes, consensus
of employee idea during staff meeting)
D.3 horizontal communication
(supply request letter, nursing referrals,
peer review feedbacks)
D.4 outward communication
(nursing administration ads for public
information)
Standard II:
A. Governance responsibility and
Governance
accountability are described in
Responsibility
organizations:
A.1 nursing service laws and policies
and
A.2 job description
Accountability
B. Persons responsible and accountable
in governing and managing nursing
service are identified by position title
and name
B.1 head nurses
B.2 Nurse supervisors
B.3 Chief Nurse

Yes

No

Remarks

Standard III:
DirectionSetting

Standard IV:
Strategic and
Operational
Plans

A.

B.

C.

Standard V:
Financial Plan
and Resource
Allocation

A.

B.

C. There is written document that

describes how the performances of
the governing entity are appraised by
specific criteria
C.1 Performance appraisal forms
A. Nursing Services Department
primarily sets its direction thru the
formulation of the following:
A.1vision
A.2mission
A.3 nursing philosophy
A.4 core values
B. The Nursing Service vision, mission,
philosophy, core values are written:
B.1 through SMART (specific,
measurable, attainable, realistic and
time bounded)
B.2updated
B.3 widely disseminated
Nursing Service governance forecast and
direct the future and operation of
Nursing Services Department to achieve
its overall goal
Existence of Strategic and operational
plans that contains:
B.1 goals and objectives
B.2 action plan activities
B.3 timeframe
B.4 resources required
B.5 Contingencies
Strategic and Management plans are
translated into actions which include:
C.1 management of patient care
C.2 nursing manpower
C.3 unit operation of
responsibility areas
Established current financial plans and
allocation of resources based on the
needs of the Nursing Services
Capital and operating budgets are
implemented as approved by authorized
office and monitored by the accounting
officer.

Standard VI:
Policies and
Procedures
Development

Standard VII:
Ethico-Moral
and Legal
Accountabilities

Standard VIII:
Professional
and
Organizational
Involvement

C. Nursing unit has an individual budget

plan periodically monitored for
variances
D. Medical supplies, materials and
equipment recommended are obtained
and appropriately used
D.1 supply inventory forms
D.2 supply request forms
D.3 wastage or losses forms
A. Developed and Implemented nursing
policies and procedures are based on
established Standards on Nursing
Administration and Nursing Service on
Patient Care.
B. The updated Manual on Policies and
Procedures in Nursing Service exists
and provides:
B.1 clear directive for nursing personnel
at different levels
B.1.a. nursing staff
B.1.b head nurses
B.1.c nurse supervisors
B.1.d chief nurse
B.2 scope and limitations of nursing
personnel functions and responsibilities
A. Policies and procedures for those
confronted by ethico-moral dilemmas in
patient care:
A.1 Do Not Resuscitate or DNR
A.2 Tubal Ligation/ Vasectomy
A.3 Therapeutic abortion
B. Nursing Service Department has a
written Code of Ethical Behavior
B.1 Dress Code
B.2 change shift procedures
A. Nursing Department initiate and
maintain formal linkage with other
departments/sections/agencies pertinent
to nursing standard:
A.1 Interdepartamental
A.1.a ANSAP
A.2.b Philhealth
A.2Intradepartamental

A.2.a Laboratory
A.2.b CSR
II.
STANDARDS ON HUMAN RESOURCE MANAGEMENT
Standard I:
A. Presence of evidences that the Nursing
Administrator
Service Administrator is qualified to the
of Nursing
position based on RA 9173;
A.1 Nurse Supervisors
Services
A.1.a Be a registered Nurse in the
Philippines
A.1.b Have at least 2 years of
experience in general nursing service
administration
A.1.c Possess a degree of Bachelor of
Science in Nursing with at least nine
(9) units in management and
administration courses at the graduate
level.
A.1.d Be a member of good standing
of accredited professional
organization of nurses.
A.2 Chief Nurse
A.2.a At least five (5) years of
experience in a supervisory or
management position in nursing
A.2.b A masters degree major in
nursing
B. Those responsible for the overall
administration and management of
nursing services is a member of the top
Executive/Management Committee who
participates in regular meetings.
Standard II:
A. Nursing Service governance develop a
Staffing Plan
staffing plan that identify;
A.1. number of desired staff
A.2 type of qualification (educational,
skills and experience)
B. Staffing plan is defined in writing and
meets the needs of the patients
population served and scope of services.
Standard III:
A. Nursing Service actively
Recruitment,
participate/collaborate in the
Selection,
development of system and processes
Hiring and
for;
A.1 recruitment

Appointment

B.

C.

Standard IV:
Credentialing

A.

B.
C.

Standard V:
Staff Placement

A.

B.

C.

Standard VI:
Staff Job
Description

A.

A.2 selection
A.3 hiring
A.4 appointment
A.5 promotion
With Legitimized and uniformly
implemented processes to;
B.1 recruit
B.2 select
B.3 hire
B.4 appoint
Staff recruitment, selection, hiring and
appointment are based on
C.1 institutional needs
C.2 patients needs
C.3 applicant qualification
Develop an effective process for
gathering, verifying and evaluating
nursing staff credentials through;
A.1 licensure
A.2 education
A.3 training
A.4 work experience
Evidence of standardized procedure to
gather the credentials of all nursing staff
Documentation of updated licensure,
education, training and work experience
of nursing personnel.
Develop and define the criteria and
processes to match the clinical staff
knowledge to patients needs.
Written core competencies required for
every job position in the Nursing
Service.
Staff placement assignment is based on
patient needs, available resources and
staff competencies
There is written job description for each
position classification of Nursing
Services personnel which specifies:
A.1 Duties and responsibilities
A.2 Accountability
A.3 Functional relationship
A.4 Qualification and experience

B.

Standard VII:
Staff
Development

A.

B.

C.

D.

E.

required
There is evidence that the job description
of Nursing Services personnel is
reviewed at least once every 3 years and
revised when necessary.
Develop and implement staff
development programs for nursing
personnel at all levels based on training
needs analyses
A.1 BLS/ACLS training
A.2 Intravenous Therapy Course
A.3 Medication Administration
A.4 Proper Documentation
Evidence of staff development programs
for all nursing personnel throughout the
year which include:
B.1 orientation program for newly hired
and promoted staff
B.2 Safety program to protect the
patient, staff and property
B.2.a Seminar on proper body
mechanics and proper patient
positioning.
B.2.b seminar on proper handling of
biochemical and others hazardous
substances such as chemotherapeutic
drugs, mercury, asbestos and the like
B.3 Continuing Education, training and
opportunities for professional
advancement of staff member
B.4 Career counseling and career
advancement/ladder
Available resources to implement the
staff development such as;
C.1 space and facilities
C.2 educational resources
C.3 clinical and clerical staff
C.4 audiovisual equipment
C.5 resources speakers
Policies and procedures on continuing
education staff attendance to staff
development programs are evident
Records of staff development program

are maintained which include:

E.1 Title of the program
E.2 Objectives of the program
E.3 Program design and content
E.4 Evaluation of the attendees
E.5 Effectiveness of the Program
E.6 List of attendees/participants
III.
STANDARDS ON FACILITY MANAGEMENT AND ENVIRONMENT
SAFETY
Standard I:
A. Comply with relevant laws, regulations
Facility
and other requirements that are
Planning
applicable
B. Actively participate in space planning as
well as medical equipment and supplies
procurement.
C. Plan and budget for upgrading or
replacing key components based on
facility inspection findings
Standard II:
A. Implementation and evaluation of
Environmental
programs/activities to manage the risks
Safety
within the environment which includes
but not limited on the following:
A.1 Safety and Security
A.1.a existing provision for the
identification of patient and their
families
- Presence of name tag, bed tags and
others identification tag
- Protocol of patient identification
A.1.b monitoring mechanism of all risk
areas including;
- medication room
- radiology room
-operating and delivery room
-treatment room
A.2 Hazardous Materials and Waste
A.2.a current list of hazardous materials
and waste to safely control them
A.2.b existing written processes of
hazardous materials including;
- handling
- labeling
- storage
- use

- inventory
- disposal
A.2.c Documentation and reporting
system in case of spills and exposure to
hazardous material/waste.
A.3 Medical Equipment
A.3.a updated policy and processes on
medical equipment in terms of;
- procurement
- inventory
- regular inspection
- preventive maintenance
- recall system
A.3.b Monitoring equipment functionality
and utilization
A.4 Utilities
A.4.a Availability of the following 24
hours a day and seven (7) days a week
- potable water
- electrical power
- medical gases
A.4.b written emergency processes in
event of;
- water interruption or
contamination
- electrical failure or
contamination
- medical gases availability
A.5 Emergencies; emergency management
plan in case of emergencies, epidemics and
disasters
A.6 Evidence of fire safety plan
A.6.a fire exit plan
A.6.b located fire extinguisher
A.6.c presence of fire alarms and fire
sprinklers
A.7 Infection Control
A.7.a evidences that policies, procedures and
guidelines are implemented
-

presence and utilization of hand

washing corner
proper use of gloves, mask, gown

and other protective gears

A.7.b there are infection surveillance,
prevention and control programs to identify
and reduce the risks of acquiring and
transmitting infections among patients and
nursing staff
-

presence of isolation room

use of triage system as admission
protocol
- report and identification of
communicable cases in the
institution in specified time and
location
A.7.c evidence that the nursing staff is
provided with education on infection control
practices
Standard III:
Staff Education

seminar and update on

management and
control of different
communicable diseases
evidence of seminar on infection
control
measures