Service Standard 04 Nursing Services

MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.
SURVEY ITEM & SELF-ASSESSMENT
SERVICE STANDARD 4 : NURSING SERVICES
PREAMBLE
The Nursing Services shall be delivered by capable, effective, competent, skillful, and highly knowledgeable nurses who will be able to provide
Patient Centric Care which includes promotive, preventive, curative and rehabilitative services. Nurses care for the whole person; physically,
mentally, emotionally, and spiritually. While caring for an individual, the nurse also cares for the family. Nurses provide care with respect and dignity
for patients and their families.
The Nursing Services shall be organised, directed and coordinated with the other services in the Facility to provide nursing care in a safe, efficient,
effective and caring manner.
TOPIC 4.1: ORGANISATION AND MANAGEMENT
STANDARD The Nursing Services shall offer high standard of care to the community, as outpatients and inpatients in a safe, effective, efficient and caring
4.1.1 manner; and shall be organised, directed and coordinated with the other services in the Facility.
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE:
RATING AREAS FOR IMPROVEMENT / SURVEYOR
RECOMMENDATIONS & RISK ASSESSMENT RATING
4.1.1.1 Vision, Mission and value statements of the Facility are accessible. Philosophies, goals
and objectives that suit the scope of the Nursing Services are clearly documented and
measurable that indicates safety, quality and patient centred care. These reflect the
roles and aspirations of the service and the needs of the community. These statements
are monitored, reviewed and revised as required accordingly and communicated to all
staff.
SERVICE STANDARD 4 – NURSING SERVICES Page 1 of 21

MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.1
1. Vision, Mission and values statements of the Facility are

available, endorsed and dated by the Governing Body.
EVIDENCE OF COMPLIANCE
2. Philosophies, goals and objectives of the Nursing Services in line
with the Facility statements are available, endorsed and dated.
3. These statements are communicated to all staff (orientation

programme, minutes of meeting, etc)
4. Achievement of goals and objectives are monitored, reviewed
and revised accordingly.
Facility Comments:
4.1.1.2 The organisational structure of the Nursing Services is clearly represented in one or
CORE more organisation charts which:
a) provides a clear representation of the structure, functions and reporting relationships

between the Person In Charge (PIC), Head of the Nursing Services, consultants,
medical practitioners and staff of the Nursing Services;
b) is accessible to all staff and clients;
c) is revised when there is a major change in any of the following:
i) organisation;
ii) functions;
iii) reporting relationships;
iv) staffing patterns.
1. Clearly delineated current organisation chart with line of functions

and reporting relationships between the Person In Charge (PIC),
Head of the Nursing Services and staff of the Nursing Services.
2. At each service level, a unit organisation chart is available which

EVIDENCE OF
COMPLIANCE
reflects the working relationships between consultants, medical

practitioners and staff of the Nursing Services.
3. Organisation chart of the service is endorsed, dated and
accessible.
4. The organisation chart is revised when there is a major change in
any of the items (c)(i) to (iv).
Facility Comments:

4.1.1.3 Regular staff meetings are held between the Head of Service and staff with sufficient
regularity to discuss issues and matters pertaining to the operations of the Nursing
Services. Minutes are kept; decisions and resolutions made during meetings shall be
accessible, communicated to all staff of the service and implemented.
1. Minutes are accessible, disseminated and acknowledged by the
staff.
EVIDENCE OF
2. Attendance list of members with adequate representatives of the
COMPLIANCE service.
3. Frequency of meetings as scheduled.
4. Discussion and resolutions are implemented (Problems not
solved to be brought forward in the next meeting until resolved).
Facility Comments:
4.1.1.4 The Head of Nursing Services is involved in the planning, justification and management
of the budget and resource utilisation of the services.
1. Minutes of Facility-wide management meeting

EVIDENCE OF
COMPLIANCE
2. Documented evidence on request for allocation of budget and

resources (staffing, equipment, etc) for the service.
3. Approved budget and resources
Facility Comments:
4.1.1.5 The Head of Nursing Services is involved in the appointment and/or assignment of staff.
1. Records on staff interview (if applicable)

2. Appointment/assignment letter.
EVIDENCE OF
COMPLIANCE
3. Job descriptions.
4. Records on staff deployment
5. Duty roster
Facility Comments:
4.1.1.6 Appropriate statistics and records shall be maintained in relation to the provision of
Nursing Services and used for managing the services and patient care purposes.

1. Records are available but not limited to the following:

a) staffing number and staff profile.
b) workload/census for inpatients and outpatients;
EVIDENCE OF
COMPLIANCE
c) staff training records.
d) data on performance improvement activities including

performances indicators and not limited to incident and near
misses reports.
e) Annual report to Governing body
Facility Comments:
4.1.1.7 The Head of Nursing Services is responsible in planning, development and evaluation
of nursing facilities and services.
1. Involvement of Nursing Ward Managers and HOS (where

EVIDENCE OF
COMPLIANCE
applicable) in the planning, development and implementation of

new policies, facilities, and services
2. Minutes of meeting
Facility Comments:
4.1.1.8 There is evidence that the Nursing Services are involved in the development and
implementation of new technologies.
1. Involvement of the nursing staff on development and

EVIDENCE OF
COMPLIANCE
implementation of new technologies.

2. Minutes of departmental/management meeting
Facility Comments:
4.1.1.9 Where the Facility provides clinical experience for students of nursing, there is a
comprehensive documented agreement between the Facility and the educational
institution detailing the responsibilities of all parties, which shall include:
a) time period;
b) liability;
c) review of terms of contract;
d) accountability for clinical nursing practice.

1. Valid Memorandum of Understanding (MOU) or Agreement
EVIDENCE OF
COMPLIANCE
2. Ratio of Clinical Instructor (CI) and students commensurate with
the number of student (1:15)
3. Student ward allocation roster
Facility Comments:

TOPIC 4.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT
STANDARD The Nursing Services shall be directed by a qualified and experienced registered nurse, and adequately staffed to achieve the goals and objectives
4.2.1 of the nursing services.
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE: AREAS FOR IMPROVEMENT / SURVEYOR
RATING
4.2.1.1 The Head and staff of the Nursing Services shall be individuals qualified by education, 1.
training, experience, certification and registration under the Nurses Registration
Regulations 1985 to commensurate with the requirements of the various positions.
1. Records on credentials of Head of Service and staff required to

fill up the posts within the service (to match the complexity of
the Facility and services) and certification/registration (Annual
Practising Certificate).
EVIDENCE OF
COMPLIANCE
2. Overall statistics of staff, qualification and experience

3. List of nurses with post basic certification in various disciplines.
4. Training and competency records
5. Deployment/assignment according to staff experience and
speciality training.
Facility Comments:
4.2.1.2 The Head of Nursing Services is a member of the Senior Management Team and sits
on relevant committees of the Governing Body.
1. Valid appointment letters and Terms of Reference as member
EVIDENCE OF
COMPLIANCE
of committees stipulated by the Governing Body.

2. Minutes of relevant committee meetings
Facility Comments:

4.2.1.3 The Head of Nursing Services shall designate a qualified registered nurse with the
delegated responsibility for the management of the Nursing Services of each unit at all
times.
1. Designated registered nurses are assigned to each unit with

delegated responsibility for management of Nursing Services.
EVIDENCE OF
COMPLIANCE
2. Letters of appointment
3. Job descriptions.
4. Duty roster
Facility Comments:
4.2.1.4 The assessment, planning, implementation and evaluation of nursing care is the
responsibility and accountability of each and every registered nurse.
1. Sample of Nursing Care Plan to ensure complete nursing

EVIDENCE OF
COMPLIANCE
process is being carried out by registered nurses as stipulated

in standard 4.3.1.9.
Facility Comments:
4.2.1.5 Nursing staffing patterns shall reflect:

CORE a) patient needs and patient acuity level of care;
b) staffing profile to comply with relevant guidelines and regulatory requirements:
i) numbers;
ii) credentials and privileges;
iii) experience of the various categories of nursing staff.
c) contingency staffing plan (absenteeism, turnover etc.).
1. Manpower planning and forecast of staffing needs.

2. Qualified staff and patient ratio meet regulatory requirements
EVIDENCE OF
3. Staff credentials and privileges.

COMPLIANCE
4. Verification of staffing needs in respective nursing service unit as reflected

by:
a) current assigned duty roster;
b) patient acuity level of care;

c) skill mix;
d) written contingency plan for turnover and absenteeism;
e) documented staff deployment communication.
Facility Comments:
4.2.1.6 There are written and dated specific job descriptions for all nursing staff that include:
a) qualifications, training, experience and certification required for the position;

b) lines of authority;
c) accountability, functions and responsibilities;
d) reviewed when required and when there is a major change in any of the following:
i) nature and scope of work;
ii) duties and responsibilities;
iii) general and specific accountabilities;
iv) qualifications required and privileges granted;
v) Statutory Regulations.
e) administrative, teaching and clinical functions.
1. Updated specific job description is available for each staff that

includes but not limited to as listed in (a) to (e).

2. Job description includes specialisation skills
3. Relevant privileges granted where applicable
4. The job description is acknowledged by the staff and signed by
the Head of Service/Unit and dated.
Facility Comments:
4.2.1.7 There is structured orientation programme for all newly appointed staff to the Nursing
CORE Services and for those new to specific areas which shall include the following:
a) Overview of Organization structure
b) explanation of the philosophy, goals, objectives, policies and procedures of the
Facility and those of the Nursing Services;
c) lines of authority and areas of responsibility;
d) explanation of particular duties and functions;
e) explanation of the methods of assigning nursing care and the standards of nursing
practice;
f) handover communication in timely manner;
g) processes for resolving practice dilemmas;

h) information about safety procedures;

i) training in basic/advanced life support techniques;
j) methods of obtaining appropriate resource materials;
k) staff appraisal procedures for the Nursing Services;
l) education on Patient and Family Rights;
m) education on all types of Accreditation Standards.
1. Policy requiring all new staff to attend a structured orientation

programme.
EVIDENCE OF
COMPLIANCE
2. There is Nursing Services orientation programme with relevant

topics not limited to topics covered from (a) to (m) and
supported by an individual area/unit specific orientation
programme.
Facility Comments:
4.2.1.8 Staff receive evaluation of their performance at the completion of the probationary period
and annually.
1. Performance appraisal for staff is completed upon probationary

EVIDENCE OF
COMPLIANCE
period and as an annual exercise.
Facility Comments:
4.2.1.9 There is evidence of training needs assessment and staff development plan which
provide the knowledge and skills required for staff to maintain competency in their
current positions and future advancement.
1. Training needs assessment is carried out and gaps identified.

2. A staff development plan based on training needs assessment
EVIDENCE OF
COMPLIANCE
is available.
3. Training schedule/calendar is in place.
4. Training module
5. Evidence of staff capacity building assessment being
monitored
Facility Comments:

4.2.1.10 There are continuing nursing education activities for staff to pursue professional
interests and to prepare for current and future changes in practice.
1. Training calendar includes in-house/external courses/
workshop/conferences.
EVIDENCE OF
COMPLIANCE
2. Contents of training programme
3. Training records on continuing nursing education activities are
kept and maintained for each staff.
4. Certificate of attendance/degree/post basic training .
Facility Comments:
4.2.1.11 Personnel records on training, staff development, leave and others are maintained for
every staff.
Note: Staff personal record may be kept in Human Resource Department as per Facility
policy.
1. Staff personal records include:
a) staff biodata;
b) qualification and experience;
EVIDENCE OF
COMPLIANCE
c) evidence of current registration;

d) training record;
e) competency record and privileging;
f) leave record;
g) confidentiality agreement.
Facility Comments:
4.2.1.12 In a Facility where nursing education programmes are conducted, the Nursing Services
shall ensure that there are sufficient skilled clinical nursing instructors with right
credentials, experience, certification and privileged to provide clinical guidance and
supervision of students.
1. Skilled Clinical Nursing Instructors with student ratio are

EVIDENCE OF
COMPLIANCE
appropriately met (1:15).

2. Written evidence to proof that continuous effort has been
taken to ensure that sufficient skilled clinical nursing
instructors are available at all times.

3. The Clinical Instructors have the right credentials and are

privileged.
4. Signed Code of Conduct by Clinical Instructor.
5.
Minutes of joint meeting between the Nursing Services with
the Nursing College.
Facility Comments:
4.2.1.13 The Nursing Services shall ensure the establishment of a mechanism which includes
CORE requirements, methodology and certification for credentialing and delineation of
privileges for nurses in specialised areas for specific procedures. The mechanism taken
by the Nursing Services shall adhere to the following:
a) the written policies and procedures documents the criteria for privileging;
b) the decisions made are objective, fair, and impartial and consistent with written
policies, procedures and criteria;
c) the granting of privileges for a specified period of time;
d) the allocation of privileges in such a way that each staff functions within a specified
area of competence;
e) the granting of privileges is approved by the Credentialing and Privileging
Committee and certified by the Person In Charge (PIC)/Governing Body.
1. Documented policies and procedures are established to govern

the credentialing and privileging processes for Nursing Services
which includes but not limited to item (a) to (e).
EVIDENCE OF
COMPLIANCE
2. There is a systematic validation process for each individual staff

member of their credentials.
3. Skills competency is assessed regularly.
4. Formal letters of assignment or certificate of privileging with
stipulated timeline are issued and reviewed accordingly.
Facility Comments:

TOPIC 4.3: POLICIES AND PROCEDURES

STANDARD There are written and dated policies and procedures for all activities of the Nursing Services. These policies and procedures reflect current
4.3.1 standards of nursing services and practice, relevant regulations, statutory requirements, and the purposes of the services.
SURVEYOR FINDINGS
SELF
RATING
4.3.1.1 There are written policies and procedures for the Nursing Services which are consistent
CORE with the overall policies of the Facility, regulatory requirements and current standard
practices which include:
a) policies and procedures, applicable laws and regulations that guide uniform nursing
care of all patients;
b) policies and procedures that guide the care of high risk patients and high risk
services:
i) emergency patients;
ii) use of resuscitation services;
iii) administration of blood and blood products;
iv) patients on life support/comatose;
v) patients with communicable disease;
vi) immuno-compromised patients;
vii) patients on dialysis;
viii) care of patients on restraints;
ix) care of elderly patients;
x) disabled individuals and children;
xi) patients receiving chemotherapy and other high risk medications.
c) policies and procedures on patient nutrition and hygiene.
These policies and procedures are signed, authorised and dated. There is a mechanism
for and evidence of a periodic review at least once in every three years.
1. Documented Policies and Procedures, Protocols, Manuals and
Guidelines are available to guide nursing care for:
COMPLIANCE
EVIDENCE OF
a) general care of all patients;

b) high risk patients as those mentioned in but not limited to
(b)

2. Policies and procedures on patient nutrition and hygiene.

3. Policies and procedures are consistent with regulatory
requirements and current standard practices.
4. Evidence of periodic review of policies and procedures.
5. The policies and procedures are endorsed and dated.
Facility Comments:
4.3.1.2 Policies and procedures are developed by a committee in collaboration with staff,
medical practitioners, Management and where required with other external service
providers and with reference to relevant sources involved.
Cross departmental collaboration is practised in developing relevant policies and

procedures where applicable.
1. Minutes of committee meetings on development and revision on

policies and procedures.
EVIDENCE OF
COMPLIANCE
2. Minutes of meeting with evidence of cross reference with other

departments.
3. Documented cross departmental policies and procedures.
Facility Comments:
4.3.1.3 Current policies and procedures are communicated to all staff.
1. Training and briefing on the current policies and

EVIDENCE OF
COMPLIANCE
procedures/Minutes of meetings
2. Circulation list and acknowledgement
Facility Comments:
4.3.1.4 There is evidence of compliance with policies and procedures.

CORE
1. Compliance with policies and procedures through:
EVIDENCE OF
COMPLIANCE
a) interview of staff on practices;

b) verify with observation on practices;
c) results of audit on practices;

d) Evidence in nursing documentation in line with established

policies and procedures.
Facility Comments:
4.3.1.5 Copies of policies and procedures, protocols, guidelines, relevant Acts, Regulations, By-
Laws and statutory requirements are accessible to staff.
1. Copies of policies and procedures, protocols, guidelines,

EVIDENCE OF
COMPLIANCE
relevant Acts, Regulations, By-Laws and statutory requirements

are accessible on-site for staff reference.
Facility Comments:
4.3.1.6 The Head of Nursing Services is responsible for the organisation, documentation and
implementation of nursing policies and procedures.
1. Policies and procedures for the Nursing Services are endorsed

EVIDENCE OF
COMPLIANCE
by the Head of Nursing Services.
Facility Comments:
4.3.1.7 The Nursing Services participate in planning, decision making and formulation of policies
of the Facility.
1. List of committees where the Head of the Nursing Services is
EVIDENCE OF
COMPLIANCE
involved.
2. Minutes of Management meetings
Facility Comments:
4.3.1.8 The Nursing Services have an established initial assessment process for patients where
their nursing needs are identified and followed by regular reassessment as deemed
necessary.

1. Nursing assessment done and completed within 24 hours of

admission.
EVIDENCE OF
COMPLIANCE
2. Nursing reassessment done as needed.
3. Nursing Care Plan documented after each nursing round with
progress of patient’s condition, dated and signed off by
attending registered nurse.
Facility Comments:
4.3.1.9 Nursing practice is in accordance with current accepted standards based on evidences
CORE and shall include in the nursing care plan:
a) documented individualised patient-focused nursing care plan for each patient to

achieve appropriate outcomes of care;
b) monitoring of the patient to assess the outcome of the care of patient;
c) reviewing and modifying the care plan where appropriate;
d) completing the care plan.
e) planning and follow up, to include discharge planning that reflects continuity of
care;
f) patient education which shall be documented.
1. Implementation of Nursing Care Plan based on patient’s need

as stated in (a) – (f)
2. Documented Nursing Care Plan signed and dated.
3. Continuity of patient care i.e. intra & inter departmental

EVIDENCE OF
COMPLIANCE
handover.
4. Patient discharge plan includes patient education.
5. Evidence based nursing services such as Bundle of Care is
adopted where applicable and appropriate.
6.
Compliance to National Patient Safety Goals related to nursing
services.
Facility Comments:

TOPIC 4.4: FACILITIES AND EQUIPMENT
STANDARD There are adequate and appropriate facilities and equipment at each nursing unit for providing safe and efficient nursing services according to
4.4.1 standards set by the relevant authorities and regulatory requirements.
SURVEYOR FINDINGS
SELF
RATING
4.4.1.1 There are adequate and appropriate facilities and equipment with proper utilisation of
space at each unit to allow staff to carry out nursing services safely and efficiently.
1.
Adequate and proper utilisation of space.
2.
Appropriate type of equipment to match the complexity of
EVIDENCE OF
COMPLIANCE
services.
3. Adequate facilities and equipment at each patient care area for
safe care. (e.g. defibrillators, emergency cart, hand washing
facilities etc)
4. Easy access and clear exit routes
Facility Comments:
4.4.1.2 Nursing Services are provided with sufficient supplies and equipment at all times,
including appropriate personal protective equipment.
1. Adequate equipment and supplies for Nursing Services.

2. Equipment are replaced in a planned and systematic manner.
EVIDENCE OF
COMPLIANCE
3. Stock inventory including personal protective equipment are

according to par level.
4. Accessibility of critical equipment and consumables at all times.
5. Equipment has valid Planned Preventive Maintenance (PPM).

Facility Comments:

4.4.1.3 Where specialised equipment is used, there is evidence that only staff who are trained
and authorised by the Facility operate such equipment.
1. User training records
EVIDENCE OF
COMPLIANCE
2. Competency assessment record
3. Letter of authorisation
4. List of staff trained and authorised to operate specialised
equipment
Facility Comments:
4.4.1.4 There are sufficient change rooms, rest areas for staff use and storage including
safekeeping of their personal items.
1. Provision of adequate staff restroom with staff personal lockers

or equivalent to keep staff personal belongings with adequate
EVIDENCE OF
COMPLIANCE
security.
2. Changing rooms at relevant care areas where appropriate.
Facility Comments:
4.4.1.5 Facilities which provide nursing training shall have specific areas for training and rooms
for tutorial.
1. Availability of training/tutorial areas/rooms.

EVIDENCE OF
COMPLIANCE
Facility Comments:

TOPIC 4.5: SAFETY AND PERFORMANCE IMPROVEMENT ACTIVITIES
STANDARD The Head of Nursing Services shall ensure the provision of quality performance and safety of patients with staff involvement in continuous safety
4.5.1 and performance improvement activities of Nursing Services in risk mitigation.
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE:
RATING AREAS FOR IMPROVEMENT / SURVEYOR
4.5.1.1 Clinical initiative to reduce risk & harm is systematically planned to minimise the adverse
consequence of patient outcomes & liability .The process includes
a) Planned activities i.e. risk identification using the risk rating matrix and develop
risk register.
b) Review risk register periodically
c) Data collection and verification
d) Monitoring and evaluation of the performance
e) Action plan for improvement
f) Implementation of action plan
g) Re-evaluation for improvement
Innovation is advocated.
1. Planned performance improvement activities include (a) to (g)

2. Records on performance improvement activities/studies

3. Minutes of performance improvement meetings
4. Nursing Risk register
5. Evidence of risk register been reviewed.

6. Records on innovation if available
Facility Comments:
4.5.1.2 The Head of Nursing Services has assigned responsibilities for planning, monitoring and
managing safety and performance improvement activities to appropriate
individual/personnel within the respective services.

1. Collection, tabulation & verification of data
EVIDENCE OF
COMPLIANCE
2. Discuss with relevant department/committee
3. Identify areas for improvement
4. Endorsement of outcome by the Head of Nursing and PIC
Facility Comments:
4.5.1.3 The Head of Nursing Services shall ensure that the staff are trained in incident reporting.
Incident reports are timely reported, investigated, discussed by the staff with learning
objectives and forwarded to the Person In Charge (PIC) of the Facility.
Incidents reported have Root Cause Analysis done and action taken within the agreed
time frame to prevent recurrence.
1. System for incident reporting is in place, which include:

a) Training of staff
b) Policy on incident reporting
c) Methodology of incident reporting
d) Register/records of incidents
2. Timely complete incident reports
EVIDENCE OF
COMPLIANCE
3. Root Cause Analysis

4. Corrective and preventive action plans
5. Remedial measure implemented and monitored
6. Minutes of meetings
7. Acknowledgment by Head of Service and PIC/Hospital
Director
8. Outcome of lessons learnt from the incident shared with others
Facility Comments:

4.5.1.4 There is evidence of tracking and trending of specific performance indicators for
CORE improvement of the services / patient care such as
percentage of intravenous (I/V) line complications (needles out, redness of skin, infection
of sites, extravasation)
(Target: ≤ 0.5%)
1. Specific performance indicators monitored.
2. Records on tracking and trending analysis.
3. Remedial measures taken where appropriate
4. Review performance indicators if trending shows consistent
achievement over one year. Identify new performance indicator
where applicable.
Facility Comments:
4.5.1.5 Feedback on results of safety and performance improvement activities are regularly
communicated to the staff.
1. Results on safety and performance improvement activities are
accessible to staff.
2. Evidence of feedback (e.g., audit on Hand Hygiene, Safe
Surgery Saves Lives, Patient Identification, Patient Fall,
Pressure Ulcer and etc) via communication on results of
performance improvement activities through continuing nursing
education activities/meetings.
3. Minutes of service/unit/committee meetings
Facility Comments:
4.5.1.6 Appropriate documentation of safety and performance improvement activities are kept,
and confidentiality of medical practitioners, staff and patients is preserved.
1. Documentations on performance improvement activities and

EVIDENCE OF
COMPLIANCE
performance indicators.
2. Policy statement on anonymity on patients and providers
involved in performance improvement activities.
Facility Comments:

SERVICE SUMMARY
SURVEYOR SUMMARY:
OVERALL RATING:
OVERALL RISK:

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MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021 | VER. 1.

SURVEY ITEM & SELF-ASSESSMENT

SERVICE STANDARD 4 : NURSING SERVICES

TOPIC 4.1: ORGANISATION AND MANAGEMENT

SERVICE STANDARD 4 – NURSING SERVICES Page 1 of 21

1. Vision, Mission and values statements of the Facility are

3. These statements are communicated to all staff (orientation

a) provides a clear representation of the structure, functions and reporting relationships

1. Clearly delineated current organisation chart with line of functions

2. At each service level, a unit organisation chart is available which

reflects the working relationships between consultants, medical

SERVICE STANDARD 4 – NURSING SERVICES Page 2 of 21

1. Minutes of Facility-wide management meeting

2. Documented evidence on request for allocation of budget and

1. Records on staff interview (if applicable)

SERVICE STANDARD 4 – NURSING SERVICES Page 3 of 21

1. Records are available but not limited to the following:

d) data on performance improvement activities including

1. Involvement of Nursing Ward Managers and HOS (where

applicable) in the planning, development and implementation of

1. Involvement of the nursing staff on development and

implementation of new technologies.

SERVICE STANDARD 4 – NURSING SERVICES Page 4 of 21

1. Valid Memorandum of Understanding (MOU) or Agreement

SERVICE STANDARD 4 – NURSING SERVICES Page 5 of 21

SURVEY ITEM & SELF-ASSESSMENT

TOPIC 4.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

1. Records on credentials of Head of Service and staff required to

2. Overall statistics of staff, qualification and experience

of committees stipulated by the Governing Body.

SERVICE STANDARD 4 – NURSING SERVICES Page 6 of 21

1. Designated registered nurses are assigned to each unit with

1. Sample of Nursing Care Plan to ensure complete nursing

process is being carried out by registered nurses as stipulated

4.2.1.5 Nursing staffing patterns shall reflect:

1. Manpower planning and forecast of staffing needs.

3. Staff credentials and privileges.

4. Verification of staffing needs in respective nursing service unit as reflected

SERVICE STANDARD 4 – NURSING SERVICES Page 7 of 21

a) qualifications, training, experience and certification required for the position;

1. Updated specific job description is available for each staff that

includes but not limited to as listed in (a) to (e).

SERVICE STANDARD 4 – NURSING SERVICES Page 8 of 21

h) information about safety procedures;

1. Policy requiring all new staff to attend a structured orientation

2. There is Nursing Services orientation programme with relevant

1. Performance appraisal for staff is completed upon probationary

period and as an annual exercise.

1. Training needs assessment is carried out and gaps identified.

SERVICE STANDARD 4 – NURSING SERVICES Page 9 of 21

c) evidence of current registration;

1. Skilled Clinical Nursing Instructors with student ratio are

appropriately met (1:15).

SERVICE STANDARD 4 – NURSING SERVICES Page 10 of 21

3. The Clinical Instructors have the right credentials and are

1. Documented policies and procedures are established to govern

2. There is a systematic validation process for each individual staff

SERVICE STANDARD 4 – NURSING SERVICES Page 11 of 21

SURVEY ITEM & SELF-ASSESSMENT