The document discusses standards for evaluating nursing services to achieve certification from the National Accreditation Board for Hospitals and Healthcare Providers (NABH) in India. It addresses 7 areas of nursing excellence: nursing resource management, nursing care of patients, management of medication, education and communication, infection control practices, empowerment and governance, and nursing quality indicators. Standards are provided for nursing resource management, including maintaining adequate nurse staffing levels according to guidelines, new nurse orientation processes, and performance management. Maintaining proper nurse staffing levels and skill mix is important to provide quality patient care.

1. NABH Nursing Excellence
Standards
Presented By:
Mr. M.S. Reddy
Nursing Officer
AIIMS, Bhubaneswar.

2. NABH
• National Accreditation Board for
Hospitals & Healthcare Providers (NABH)
is a constituent board of Quality Council of India,
set up to establish and operate accreditation
programme for healthcare organizations.

3. Vision, Mission of NABH
• To be apex national healthcare accreditation and
quality improvement body, functioning at par with
global benchmarks.
• To operate accreditation and allied programs in
focusing on patient safety and quality of healthcare
based upon national/international standards.

4. Scope of NABH:
• Accreditation of healthcare facilities
• Quality promotion initiatives like Safe-I,
Nursing Excellence, Laboratory Certification
programs.
• IEC activities: Public Lectures, advertisement,
workshops/ seminars
• Education and Training for Quality & Patient
Safety

5. • These are the 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 of hospital

6. Nursing Excellence is measured in
terms of:
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).

7. Nursing Resource Management
• The goal of nursing resource management is to
acquire, provide, retain and maintain
competent nursing staff in right numbers to
meet the needs of the patients and community
served by the Organization.

8. Standards Of Nursing Resource
Management:
1. The organization will have a documented system
of nursing resource planning
2. The organization possess structures and processes
for induction.
3. The organization will have process in place In-
service education and Continuous Nursing
Education (CNE) Programmes .
4. There is a process for credentialing and
privileging of nursing professionals, permitted to
provide patient care without supervision.

9. 5. An appraisal system for evaluating the performance
of nursing staff exists.
6. There should be a provision for acknowledging
outstanding performances/ contributions of nursing
professionals.
7. There will an established process in place to
identify and manage problems related to
incompetent, unsafe or unprofessional conduct.
8. The organization will demonstrate workplace
safety for nursing professionals.
9. The organization will have a documented and
established grievance handling system.

10. 1. The organization will have a
documented system of nursing
resource planning.
• The Nursing resource planning supports the
organization's current and future ability to meet
the care, treatment and service needs of the patient.
• It shall use recognized methods for determining the
adequacy of nursing staffing.

11. Nurse to population / patient ratio in
India
Nurse /
Population
WHO
Recommendations
Nurse/ Patient WHO
Recommendations
1: 1100 1: 500 1:40 1:4

12. Composition Of Health Force In
India (WHO 2016)

13. • The organization will ensure that the plan
addresses staffing crisis situations due to
attrition, and the hiring plan ensures vacancies
are filled up early so that patient care is not
compromised.

14. Norms of Staffing (SIU- Staff
Inspection Unit)
• The Staff Inspection Unit (S.I.U.) is the unit
which has recommended the nursing norms in
the year 1991-92.
• As per this S.I.U. norm the present nurse-
patient ratio is based and practiced in all
Central Government Hospitals.

15. The Nurse-patient Ratio as per
the S.I.U. Norms
S.No Area Nurse Patient Ratio
1 General Wards 1 Staff Nurse/Nursing Sister for every 6
beds (1:6)
2 Special Wards
i. Pediatrics
ii. Burns
iii. Neuro surgery
iv. Cardio thoracic
v. Neuro medicine
vi. Spinal injury
vii. Emergency wards attached to
casualty
1 Staff Nurse/Nursing Sister for every 4
beds (1:4)
3 ICU/ICCU/Nephrology 1 Staff Nurse/Nursing Sister for every 1
beds (1:1)

16. S.No Area Nurse Patient Ratio
4 Labour Room 1 Staff Nurse/Nursing Sister for every
labour table (1:1)
5 O.T.-
Major
Minor
2 Staff Nurse/Nursing Sister for every
functional operation table(2:1)
1 Staff Nurse/Nursing Sister for every
functional operation table (1:1)
6 Casualty
Attendance up to 100 patients per day.
Thereafter for every additional
attendance of 35 patients per day
3 Staff Nurses/Nursing Sister for 24
hours
1 Staff Nurse/Nursing Sister
7 O.P.D. (Injection room)
Attendance up to 100 patients per day
Attendance up to 120-220 patients per
day
Attendance up to 221-320 patients per
day
Attendance up to 321-420 patients per
1 Staff Nurse
2 Staff Nurses
3 Staff Nurses
4 Staff Nurses

17. INC NORMS(1985)
S.No Name of the Post Ratio
1 Chief Nursing Officer 1 CNO for the hospitals more than 500 beds
2 Nursing Superintendent 1 per 400 beds or above
3 D.N.S 1 per 300 beds and 1 additional for every 200 beds
4 A.N.S 1 for 100-150 beds or 3-4 wards
5 Ward Sister 1 for 25-30 beds or one ward. 30% leave reserve
6 Staff Nurse 1 for 3 beds in Teaching Hospital in general ward& 1
for 5 beds in Non-teaching Hospital +30% Leave
reserve
7 Extra Nursing staff to be provided for departmental research function.
8 For OPD and Emergency : 1 Staff Nurse for 100 patients (1 : 100 ) + 30% leave
reserve
9 For Intensive Care unit (I.C.U.): 1:1 +30% leave reserve
10 It is suggested that for 250 bedded hospital there should be One Infection Control
Nurse.
For specialized departments, such as Operation Theatre, Labour Room, etc. 1:25
+30% leave reserve.

18. • The organization must maintain an adequate
number and mix of nursing staff to meet the
care, treatment and service needs of the
patient.
• The nursing staff should be commensurate
with the workload and the clinical requirement
of the patients.

19. Nursing Care Hours Per Patient /
Day in India:
S.No Area Average Hours Of
Care/ Day
Professional To Non
Professional work
Ratio
1 General Medicine 3.5 60:40
2 Medical 3.4 60:40
3 Surgical 3.4 60:40
4 Obstetrics 3.0 60:40
5 Pediatrics 4.6 70:30
6 ER/ICU/CCU/ Recovery Room 6.0 70:30

21. A ward will be unable to provide a good standard of care
without a good duty roster
Things to consider while making a duty roaster:
• Determine the total no of nursing staff required
• Fill busy shifts with the most experienced and skilled staff.
• Assess the Ability of the staff to cover the needs of the unit
• Rosters must make appropriate provision for adequate staff
supervision, training and clinical handover.
• Fairness to the staff – fair share of weekends, holiday offs,
rotating the staff including assignment to “difficult” or
“light” or “undesirable” units or shifts
• Stability – the schedule must be harmonized with their
family or social activities of the staff
• Flexibility – ability to handle changes brought by
emergency leaves

22. The person heading the nursing service should
have requisite and appropriate qualifications
and experience.
The required job specification and job
description should be defined for each
category of nursing staff.

23. JOB DESCRIPTION:-
Contains particulars of the activities to be performed and the characteristics
of employees required.
NURSING OFFICER:
Nursing officer is directly responsible to Senior Nursing Officer (Ward In
Charge) for total nursing care of the patient assigned to him/her.
A. DIRECT PATIENT’S CARE:
1. Admission and discharge of the patients.
2. To maintain the personal hygiene of the patients, including bathing, care
of mouth, back, nails, hair etc.
3. Care of pressures points as needed.
4. To assist the patient in elimination, feeding the weak and debilitated
patients.
5. Writing of diet sheet, Supervision and distribution of diets.
6. Assist in physiotherapy, ambulation and rehabilitation.
7. Carry-out patient’s teaching and demonstration according to the need.
8. Counseling the patients, and relatives.
9. Care of the dying and dead.
10. Administration of Medicines and Injections to the patients.

24. 11.Observing, recording and reporting of vital signs .
12.Carry out technical procedures, such as Naso-
gastric intubation, Gastric Gavage and Lavage,
Oxygen Therapy, Dressing and Irrigation, Enema,
Catheterization, hot and cold applications, suction
etc.
13.Collecting, labeling and dispatch of specimens.
14.Preparation for and assistance in clinical tests and
medical/surgical procedures.
15.Observation, recording and reporting of all
procedures and tests.
16.Escorting serious patients to and from the
department/wards for investigations.

25. B. WARD MANAGEMENT:
1. Handing over and taking over charge of patients, and ward inventory in each
shift.
2. Maintenance of therapeutic environment in the ward.
3. Keeping the ward clean and tidy.
4. Routine care and maintenance of dressing trolleys, cupboards, apparatus,
mackintosh etc.
5. Care of clean and soiled linen.
6. Disinfection of linen, beds, floor and bed pans, and fumigation of rooms etc.
7. Preparation of room, trolleys, and sets for procedures.
8. Preparation of surgical supplies.
9. Maintaining interpersonal relationship with patients, relatives and health team
members.
10. Orientation of new staff/students.
11. Demonstration and guidance to student nurses.
12. Participation in staff education and staff meetings.
13. Participation in professional activities.
14. Demonstration and supervision of domestic staff.
15. Report about the medico-legal cases if any admitted in the ward. To keep the
senior nursing officials informed of the happenings / in the ward like fire,
absconding patients, theft etc.
16. Any other duty that may be assigned by Senior Nursing Officer from time to
time.

26. 2. The organization possess
structures and processes for
induction

27. • Training need shall be identified on a continual
basis by the senior nursing professionals as
well as the Clinical Heads as appropriate.
• The staff will be trained and the same can be
recorded in the training records.
• Every nurse entering the organization is
provided induction training.

28. • The induction training shall be conducted
within 15 days of the staff joining.
• The contents of this training could be provided
to every nursing staff in the form of a booklet.
• There can be separate induction training at the
organizational level and for the respective
departments.

29. 3. The organization should have
processes in place for In-service
education and Continuous Nursing
Education (CNE) Programmes

30. • The organization will have an training and
development policy and the training
calendar
• The organization must have all the records
of training.
At a minimum, it shall include the title of the
training, the trainer(s), list of trainees (with
signatures) and the post-training feedback.

31. • Nursing professionals shall receive adequate
training when there is a change in job
responsibilities or when new equipment is
introduced.
• The training should focus on the revised job
responsibilities as well as on the newly
introduced equipment and technology.

32. • All nursing staff should be trained to provide
BLS (Basic Life Support).
• Nursing professionals working in intensive
care/high dependency units shall undergo
training in ACLS or PALS or NALS as
applicable.

33. Common areas of training
Nursing officers Senior Nursing Officers/ ANS/DNS/ NS
1. Patient safety
2. Nursing Process
3. Human Relations in
Nursing
4. Ethical and Legal issues in
clinical nursing
5. Pre and post operative
Nursing Management
6. Stress Management
7. Medication
Administration Safety
1. Human Relations in
Nursing
2. Materiel Management
3. Ethical and Legal issues in
clinical nursing
4. Conflict Management
5. Stress Management
6. Nursing Administration

34. 4. There should be a process for
credentialing and privileging of
nursing professionals, permitted to
provide patient care without
supervision.

35. • The education, registration, training and
experience of nursing staff is recorded and
updated periodically.
• Updation is done after verifying the credentials
from the organization which has awarded the
qualification/training/ experience.
• Nursing staff are granted privileges and provide
care in consonance with their qualification,
training, experience and registration.

36. 5. An appraisal system for
evaluating the performance of
nursing staff should exist.

37. • A recorded performance appraisal system should
exist in the organization for nursing professionals.
• The nursing professionals are made aware of the
system of appraisal at the time of induction.
• Performance is evaluated based on the pre-
determined criteria.
• Performance appraisal is carried out at pre-
defined intervals and is recorded. This shall be
done at least once a year.

38. 6. There is a provision for
acknowledging outstanding
performances/ contributions of
nursing professionals.

39. National Florence Nightingale Nurses
Award winners- 2018

40. • Patients, families and staff shall be encouraged to
report positive feedback about nursing care
delivered in relevant areas.
• Nursing staff with managerial responsibilities shall
ensure that soft skills in nursing, qualities of
leadership and professional competence are duly
reported to higher authorities.

41. 7. The organizations should
have an established process in
place to identify and manage
problems related to
incompetent, unsafe or
unprofessional conduct.

42. • The process shall include daily monitoring of
appearance and ability to impart nursing care,
appearance, behaviour and communication.
• The process shall include analysis of all complaints
pertaining to nursing services specifically
addressing individual nursing staff.
• The process shall ensure that there is no
victimization and corrective action is focused
against the system rather than the individual.

43. • The disciplinary policy and procedure is based
on the principles of natural justice.
• Principles of natural justice shall be followed
to ensure that a nursing staff against whom
there is a complaint, of any sort, has the right
to explain himself/herself.

44. 8. The organization should
demonstrate workplace safety
for nursing professionals

45. • Management should provide resources related to
workplace safety for nursing professionals.
• There shall be sufficient change rooms,
washrooms & dining facilities for nursing staff.
• Management shall ensure that there is a
mechanism whereby any safety related issues are
duly reported.

46. • The Management should promote a culture of
reporting of safety related issues such that
there is no victimization.
• This also includes setting of a gender
harassment committee to ensure workplace
safety from sexual harassments.
• A record of corrective and preventive actions
shall be maintained wherever appropriate, with
due consideration given to anonymity.

47. ICC / Women Cell, AIIMS, BBSR

48. 9.The organization should have a
documented and established
grievance handling system.

49. • The organization should have a well-defined
process for handling nurse (s) grievances
• The nursing professionals are educated about
the mechanisms available for addressing
grievances.

50. Grievance Cell, AIIMS ,BBSR

51. • The head of the nursing service protects
nurse (s) rights
• The nursing professionals are educated
about their rights.

52. Rights Of Nurses:
• Right to practice in a manner that fulfills their obligations to
society.
• Right to practice in environments that allow them to act in
accordance with professional standards and legally
• Right to a work environment that supports and facilitates
ethical practice
• Right to freely and openly advocate for themselves and their
patients without fear of retribution (punishment)
• Right to fair compensation for their work
• Right to a work in a environment that is safe for themselves
and their patients
• Right to negotiate, either as individuals or collectively, the
conditions of their employment

53. EDUCATION,
COMMUNICATION AND
GUIDANCE

54. EDUCATION, COMMUNICATION
AND GUIDANCE (ECG)
• Objectives:
• The organization must ensure that nursing
professionals are trained in communication skills.
• Nursing professionals will able to communicate as
and when required with relevant team members to
achieve continuity of care.
• To provide timely guidance to the patients and
families about their healthcare needs .

55. Measures to promote ECG
• All the nursing staff should be trained to meet
the patients specific needs.
• The communication needs of patients who
speak different language than the care givers is
to be addressed
• Training is imparted to address the patient's
needs with impaired communication.
• The nursing professionals should be aware of
patient rights.

57. PATIENTS RESPONSIBILITIES
• Providing information regarding past health history
• Following physicians instructions
• Participating in decision making
• Asking for information or clarification if they don’t
understand anything fully
• Responsible to refrain from misbehaving and
physical assault with health care workers
• Making payments wherever applicable
• Not to disturb the fellow patients
• Bounding to the hospital rules and regulations

58. • Nursing professionals are reminded to maintain
the confidentiality of patients information.
• Maintain privacy of the patients during care.
• The nursing professionals support individual
patient and family beliefs, values and customs
and involve the patient and family in decision
making processes.

59. • Proper handover mechanism is to be
established among the care team across shifts
regarding patient's status.

61. • Nursing professionals communicates with staff
in other departments when required to ensure
that care plan is implemented.
• HCO uses predetermined formats for such
communication wherever required.
• Educate the patients on the medical condition,
pre and post-operative education, special
procedures, preventing healthcare associated
infections, when to seek urgent medical attention
and home care.

62. • Ensure written informed consent wherever
essential.
• Patient and/or family are educated in a
language they can understand.

63. Summary:
• Documented nursing resource plan
• Induction plan
• CNE, In-service education
• Privileging
• Acknowledgment of contributions
• Work place safety
• Grievance handling system
• Principle of natural justice
• Confidentiality of information
• Patients rights
• Health education