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NABH Nursing Excellence Certification Project
By: Mr. Kirankumar GhanapuramConsultant – Healthcare Management
[email protected]+ 91 9011017501
INTRODUCTION
• Program For Nursing Excellence
• Promotion of safe, effective, competent and
ethical nursing care
• Evaluate nurses and act as a catalyst for self
regulation and improvement
• Nursing services are an integral part of the
clinical services of any health care
organization.
• NABH Nursing Excellence contains complete
set of standards for evaluation of nursing
service for grant of certification.
• The standards provide framework for quality
of care for patients and quality improvement
for nursing services.
• Applicable to all the Health care organizations
irrespective of their size, role and complexity
• Serve as guidelines to nurse administrators
and supervisors for supporting and facilitating
safe, competent and ethical nursing practices
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• Aim of nursing services - to provide
comprehensive nursing care in terms of
health promotion, prevention of diseases and
therapeutic nursing care to the patients in a
HCO as well as to the community.
• Objective of the nursing professional - to
provide safe, competent and ethical nursing
care with compassion, comfort and
collaboration with the patients, the family, the
community and the clinical care team.
• Increasing demands of quality improvement
activities
• Nurses’ roles in quality improvement
• Challenges with regard to nursing involvement
• Nurses are - The key caregivers in hospitals,
Integral to hospitalized patients’ care, Pivotal
in hospital efforts to improve quality,
Cornerstone of any quality related
programme, Making all the difference in the
ultimate delivery of health care.
BENEFITS
Benefits for Patients
• Patients are the biggest beneficiary among all
the stakeholders
• The patients are serviced by credential
nursing staff which results in high quality of
care and patient safety
Benefits for Hospitals
• This certification programme stimulates
continuous improvement.
• It enables Hospital in demonstrating
commitment to quality care.
• It raises community confidence in the services
provided by the hospital
• It also provides opportunity to
• Healthcare unit to benchmark with the best.
Benefits for Nursing Staff
• An environment that recognizes and rewards
competence
• Professional growth and development by
educational opportunities and support
• A structure that encourages decision making
at the bedside over clinical issues
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• High job satisfaction
• Low turnover and more stability
• Focus on professional autonomy
• Enhanced Interdisciplinary collaboration
• Professional growth opportunities
• Leadership opportunities
• Opportunity to practice professional nursing
with strong interdisciplinary teamwork that
support autonomous practice of nursing
• A culture that supports you to be the best
nurse you can be!
NURSING EXCELLENCE STANDARDS
• Complete set of standards for evaluation of nursing service for grant of certification
• Framework for quality of care for patients and quality improvement for nursing services
• Help to build a quality culture at all level and across all the function of hospital
• Nursing Excellence Standards has 07 chapters incorporating 48 standards and 216 objective
elements.
• Outline of NABH Nursing Excellence Standards
1. Nursing Resource Management (NRM).
2. Nursing Care of Patient (NCP).
3. Management of Medication (MOM).
4. Education, Communication and Guidance (ECG).
5. Infection Control Practices (ICP).
6. Empowerment and Governance (EG). 7. Nursing Quality Indicators (NQI).
CHAPTER 1 (NRM)
NURSING RESOURCE MANAGEMENT (NRM)
NRM.1: The organization has a documented system of nursing resource planning
NRM.2: The organization has structures and processes for induction and for enhancing the transition of
novices to competent nursing professionals.
NRM.3: The organization has processes in place for induction training, In-service education and
Continuous Nursing Education (CNE) programmes and for documentation of the same in the personal
files.
NRM.4: There is a process for credentialing and privileging of nursing professionals, permitted to
provide patient care without supervision.
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NRM.7: There is an established process in place to identify and manage problems related to
incompetent, unsafe or unprofessional conduct.
NRM.8: The organization demonstrates workplace safety for nursing professionals (including change
rooms, washrooms & dining facilities).
NRM.9: The organization has a documented and established grievance handling system.
CHAPTER 2 (NCP)
NURSING CARE OF PATIENTS (NCP)
NCP.1: A Nursing Manual shall be established and
reviewed periodically as defined by HCO
NCP.2: The initial assessment shall be done by the
nursing professionals in predetermined format at
prescribed time and/or as per the needs of the
patients.
NCP.3: The reassessment shall be done by the
nursing professionals in a predetermined format at
prescribed time.
NCP.4: For provision of nursing care, appropriate
number of nursing professionals shall be
maintained as per workload.
NCP.5: The nursing care planned and provided by
the nursing professionals is recorded.
NCP.6: The nursing care is individualized to address
the needs of patient and family.
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NCP.7: Information is exchanged and documented during each staffing shift, between shifts, and during
transfers between units/departments.
NCP.8: There shall be established policies and protocols for vascular access devices. (VADs).
NCP.9: The nursing care of inpatients shall be supervised by senior nursing professionals.
NCP.10: The nursing care of vulnerable patients (elderly, children, physically and/or mentally
challenged) shall be supervised by senior nursing professionals.
NCP.11: The nursing care of patients under restraints (physical and/or chemical) shall be supervised by
senior nursing professionals.
NCP.12: Appropriate pain management practices shall be supervised by senior nursing professionals.
NCP.13: Appropriate end of life care shall be provided to patients needing the same by the nursing
professionals.
CHAPTER 3 (MOM)
MANAGEMENT OF MEDICATION (MOM)
MOM.1: Indenting of required medication and stores will be
done and supervised by nursing staff made responsible for this
function. Storage of medication in the wards and other
therapeutic areas shall be supervised by responsible nursing
professionals.
MOM.2: The dispensing, administration and accounting of
medicines shall be carried out by the concerned personnel and
should be appropriately supervised by senior nursing staff.
MOM.3: The monitoring of patients after medication
administration is supervised by responsible personnel.
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MOM.4: The nursing professionals must report
near misses, medication errors and adverse drug
events as per the policy of the HCO for analysis by
the appropriate staff predefined and identified by
the HCO. Feedback is provided to staff which
includes the results of analysis and recommended
preventive measures for implementation by the
nursing staff wherever appropriate.
MOM.5: The organization shall ensure that it has a
policy on verbal orders which will be applicable to
doctors, nursing professionals and technicians
uniformly.
CHAPTER 4 (ECG)
EDUCATION, COMMUNICATION AND GUIDANCE (ECG)
ECG.1: The organization shall ensure that nursing professionals are trained in communication skills.
ECG.2: Nursing professionals are aware of their responsibility in protecting patient rights.
ECG3: Nursing professionals communicate as and when required with relevant team members to
achieve continuity of care.
ECG.4: Patient and family are educated where essential and in case of any change in nursing care plan.
CHAPTER 5 (ICP)
INFECTION CONTROL PRACTICES (ICP)
ICP.1: Infection control nurse (s) shall be designated by the organization
ICP.2: Nursing professionals shall adhere to standard precautions and hand hygiene guidelines at all
times.
ICP.3: The nursing professionals shall adhere to handling, storage and disposal of bio medical waste as
per the bio medical waste management Act, 1998
ICP.4: The designated nursing staff shall perform surveillance activities to capture and monitor infection
control and prevention data.
ICP.5: Isolation (barrier and reverse barrier nursing) practices shall be supervised by senior nursing
professionals.
ICP.6: Infection Control Nurse maintains records of all occupational injuries and pre- and post-exposure
prophylaxis.
CHAPTER 6 (EG)
EMPOWERMENT AND GOVERNANCE (EG)
EG.1: The responsibilities of those responsible for
nursing management are defined.
EG.2: The Head of the Nursing service ensures that
suitable mechanisms exist to govern the nursing
Service.
EG.3: Nursing professionals are involved and
participate in decision making related to
organization and nursing services.
EG.4: The Management empowers nursing staff.
EG.5: The organization has an established process
for proactive risk assessment and error
management.
EG.6: The infection control programme is supported
by the management and includes training of staff.
CHAPTER 7 (NQI)
NURSING QUALITY INDICATORS (NQI)
NQI.1: There is a structured quality improvement and continuous monitoring program for nursing
service.
NQI.2: The organization identifies key indicators to monitor the structures, processes and outcomes,
which are used as tools for continual improvement for nursing service.
NQI.3: The nursing quality improvement programme is supported by the management.
NQI.4: There is an established system for nursing audit.
NQI.5: Incidents, complaints and feedback from nursing professionals are collected and analysed to
ensure continual quality improvement.
PREPARING FOR NURSING EXCELLENCE CERTIFICATION
• Strong Commitment
• A definite plan of action – Strategy
• An official nomination of Nursing Excellence
programme Coordinator (Preferably from
nursing)
• Procure a copy of Nursing Excellence
standards
• Self-assessment against NABH standards at
least 3 months before submission of
application is must
CERTIFICATION PROCEDURE
• Application for certification
– Prescribed application cum first year
certification fee as detailed in the
application form
– Filled in Self Assessment Toolkit,
available free on the web-site.
– Nursing Manual (as per NABH Nursing
Excellence standards) and other NABH
relevant documents i.e. different
policies and procedures of the hospital
• Scrutiny of application
• Assessment - comprehensive review
– A Principal Assessor/ Assessment Team
- depend on the number of beds
• The date of assessment
– Assessment report
» Corrective action report
• Scrutiny of assessment report
• Issue of Certificate
• Re assessment
CONTACT US FOR
Our consulting services are
• NABH (All Level)
• NABH Safe I
• ISO 9001:2015
• Nursing Excellence
• Medical Laboratory Programme
• Emergency Department Standards
• Medical Facilitator Programme
Mr. Kirankumar
Ghanapuram
Consultant - Healthcare
Management
+91 9011017501
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