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· Standard I
–  (The nursing department / services shall be directed by a qualified nurse administrator and shall be appropriately integrated with the medical staff and with other hospital staffs that provide and contribute to patient care)

The administrator of the nursing department service shall be qualified, registered nurse with appropriate education, experience, and licensure and demonstrated ability nursing practice and administration

· Standard II
–  (The nursing department / service shall be organized to meet the nursing care needs of patients and to maintain established standards of nursing practice)

The nursing department / services shall have a written organizational plan that delineates lines of authority, accountability, and communication. The manner in which the nursing department / service is organized shall be consistent with the variety of patient services offered and the scope of nursing care activities

  •  Reviewing and approving policies and procedures
  •  Establishing standards of nursing care
  •  Accounting for professional and administrative nursing staff activities
  •  Implementing the approved policies of the nursing department/services
  •  Appointing committee as needed
  • Encouraging nursing staff personnel to participate in staff education programs

· Standard III
–  (The nursing department / services assignments in the provision of nursing care shall be commensurate with the qualifications of nursing personnel and shall designed to meet the nursing care needs of patients)

A sufficient number of qualified registered nurses shall be on duty at all times to give patients the nursing care that requires the judgment and specialized skills of a registered nurse

· Standard IV
–  (Individualized, goal directed nursing care shall be provided to patients through the use of the nursing process)

The nurse process (assessment, planning, intervention, evaluation) shall be documented for each hospitalized patient from admission through discharge

·  Standard V
– (The nursing department / services personnel shall be prepared through appropriate education and training programs for their responsibilities in the provision of nursing care)

Education / training programs for the nursing department / services personnel shall be ongoing and designed to augment their knowledge of pertinence new developments in patient care and to maintain current competence. The scope and complexity of the program shall be based on the documented education needs of nursing staff personnel and resources available to meet those needs

·  Standard VI
– ( Written policies and procedures that reflect optimal standards of nursing shall guide the provision of nursing care)

Written standards of nursing practice and related policies and procedures shall define and describe the scope and conduct of patient care provided by the nursing staff. These standards, policies, and procedures shall be reviewed at least annually, revised as necessary, dated to indicate the time of the last review, signed by the responsible reviewing authority, and implemented     

·  Standard VII
– ( As part of the hospital’s quality assurance program, the quality and appropriateness of the patient care provided by the nursing department / services are monitored and evaluated, and identified problem are resolved)

The nursing department / services has planned and systematic process for monitoring and evaluation of the quality appropriateness of patient care and for resolving identified problems


                                     Dr. Rajha Abdul-Hassan Hamza

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