Final Nursing Manual Administraton - 7327 - 16636 PDF

NURSING
Administration
FORTIS HEALTHCARE LIMITED
NSG/ADM/1.0
Nursing Department: Administrative SOP Pages /1- 56
Nursing Department: Administrative SOP

1. Vision
Saving and enriching lives
2. Mission
To offer a patient-centric, distinctive health care environment where patients and caregivers
are treated with compassion and respect while providing safe, evidence-based, nursing
services.
3. Fortis Nursing Values

Patient Centricity: Treat patients and their caregivers with compassion, care, and
understanding in all nursing tasks and duties.
Ownership: Be responsible and take pride in all actions
Integrity: Demonstrate moral courage to speak up, be honest, principled and always
do the right things.
Innovation: Continuously improve and strive to exceed expectations.
Teamwork: Respect, value and proactively support all co-workers and operate as
one team.
4. Objectives
Treating patient and his family/significant others as one inseparable unit
Upholding the rights of patient and family
Actively participating in the patient/family care planning
Gaining and giving co-operation to all the other departments
Seeking ways for continuous improvement through on going education, training and
certification
Sharing and upholding the vision of the organization
Giving and earning trust in our interpersonal relationships
Imparting health teaching to patients and their family/significant others to ensure
speedy recovery and maintenance of health.
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5. Scope of Services
The nursing department provides round the clock services in the following departments
I. Departments:
Emergency Room (ER): - Includes Triage in all hospitals and High Dependency Unit (HDU) in
some of the hospitals. Nurse patient ratio is 1:2.
Triage: All patients coming to ER are assessed and sorted for first aid, stabilization and
admission or stabilization and discharge
High Dependency Unit (HDU): - This unit caters to all critically ill patients requiring close
monitoring and constant observation and nursing care without artificial ventilation. High
dependency Unit has a nurse patient ratio of 1:3
Intensive Care Units: Intensive Care Units consists of monitored intensive care beds where
in all critically ill or postoperative cases are taken care of. The nurse patient ratio here is
1:1.25 –2. The units are equipped with bedside monitors, central monitoring system, facility
for invasive and non-invasive ventilation and other invasive monitoring facilities. The name
of the ICU can vary from unit to unit depending on the patient population that it caters to.
Some of the common specialty ICUs is as follows –
Cardiac Surgical Intensive Care Unit/Surgical Intensive Care Unit (CSICU/SICU) - All Cardio
Thoracic Vascular Surgery (CTVS) post-op patients are taken care till the day they are fit to
be transferred back to patient rooms. Some critically ill pre-op patients are also admitted to
this unit.
In hospital where no separate CSICU, other specialty cases TKR, THR, Craniotomy) and
surgical patients who require critical monitoring and ventilatory support are also admitted
to the unit.
Pediatric Intensive Care Unit (PICU) –
This is the pediatric ICU who require critical monitoring, ventilator support are admitted
Coronary Care Unit (CCU) - All critically ill cardiac patients are admitted here. All post PTCA,
post PPI, Post EPS, RFA, non-surgical closure of ASD & VSD & post ICD implantation patients
are also kept here in the immediate post-procedure period. The stay varies from few hours
to 1-2 days. In units where separate CCU is not present, patients are admitted in either SICU
or MICU.
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Medical Intensive Care Unit (MICU) - This unit caters to non surgical all critically ill patients.
Wards - The wards consist of single rooms, twin and triple sharing and ward rooms. The
nurse patient ratio here is 1:6 or 1:7
Operation Theaters - Consists of all operation theaters according to specialty. Multispecialty
Operation Theater services include Eye, ENT, General surgery Gynecology, Plastic Surgery,
Gen. Surgery Dental and Urology. In units specializing in Neuro, Ortho, and Cardiac,
surgeries specific OTs and /or time slots are demarcated unless the hospital has special OTs
for these specialties. The nurse table ratio is 2:1
Cardiac Operation Theater (COT) – In units with dedicated cardiac OT, all types of cardio-
thoracic surgeries are done. Commonly done surgeries are CABG, MVR, AVR, DVR,
Correction of TOF, ASD & VSD, and Repair of Aortic Aneurysms. Thoracic and vascular
surgeries are infrequently undertaken
Renal Operation Theater (ROT) - In units with dedicated ROT all types of renal surgeries are
undertaken.
Ortho Operation Theater (OOT) - In units with dedicated Ortho OT all types of ortho
surgeries are undertaken including joint replacements.
Catheterization Laboratory (Cath Lab) - All invasive cardiac procedures are done here. The
procedures done here include: CAG, PTCA, TPI, IABP insertion, PPI, EPS, RFA, IVC Filter, ASD
& VSD closure & ICD implantation.
Out Patient Department (OPD) - Here all in-house and empanelled consults have slots for
their consultation. The nursing here supports Non-Invasive Cardiology, Radiology, Nuclear
Medicine, Diabetic Clinic & Blood Bank also. Nurses here render assistance to the
consultants in way of taking vital signs and assisting in OPD Procedures.
Dialysis Unit - The Dialysis Unit runs in two/ three shifts and all outpatient and in-patient
dialysis is undertaken here. Portable dialysis units are used for bedside dialysis of critically ill
admitted patients.
II. Services cover the following areas:
Patient Assessment
Patient admissions in all units take place through Triage in emergency cases and during
nonworking hours/holidays and through OPDs during working hours.
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All beds are kept ready for the patient’s admission at all times. Beds are allocated by IPD in
consultation with the respective unit in charges. As soon as the patient arrives, initial
assessment is done by the assigned nurse, by checking the documents, collecting relevant
history and doing a quick physical examination.
The patient needs are identified, and necessary medical/nursing orders are carried out. The
patient and significant others are given orientation to the ward, patient protocols are
explained.
All the investigative/therapeutic and nursing procedures are explained to the patient and
significant others. All the necessary and relevant patient education is carried out by the
designated nurse or the nurse patient educator (if the unit has one)
The types and ages of patients served
Patients of all age group are admitted to the units. Patient acuity ranges from completely
dependent patients in ICUs to partially dependent patients in the wards.
The extent to which the level of care/ service provided meets customer needs
The nursing department caters to meet cent percent nursing needs of the clients. The
recommended staffing is maintained round the clock. To improve the efficiency levels of the
staff; continuing education programs are planned and carried out by the Nursing Education.
Appropriateness, clinical necessity, timeliness of support service provided
The Nursing Department maintains the intensity of service provided 24X 7 in all units except
in OPD’s which are closed during non-working hours/holidays. On call services are provided
by Dialysis nurses in nonworking hours/ holidays.
III. Interdepartmental communication
Nursing maintains Interdepartmental communication with the following departments-
F & B (Food and Beverages)
Diet for patients is always requested by the Nurse
Appropriate therapeutic diet is planned by dietician after nutritional assessment.
Appropriate intimation is provided by the Nurse to dietetics department when a diet
is changed or when there is a patient transfer/discharge.
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Engineering & Bio Medical Department
The Charge Nurse sends the request for maintenance & repairs to these
departments as soon as the need is identified.
The nurses share joint responsibility for handling /care of biomedical equipments
and other fixtures in the patient care areas
The Nursing team works in conjunction with Engineering and Bio Medical to ensure
timely check and preventive maintenance of all equipments and fixtures is done.
Biomedical and Engineering department is called periodically for training needs of
nurses about biomedical equipments training by the nursing education as and when
required.
Laundry
Nurses liaises with Laundry for all linen requirement as per the hospital protocol
House Keeping
Nurses are supported by House Keeping to ensure a clean and safe environment in all areas
as per set hospital standards.
Inpatient Department (IPD)
Does accurate & timely co-ordination with IPD on transfers, admission, discharges &
deaths
Filling up of billing activity (as per set guidelines of the hospital)
Clearance for procedures & surgeries are obtained from IPD desk
Discharge clearance is obtained from IPD before physically allowing the patient to
leave the hospital.
Stores
Indent all consumables, drugs and stationery from the stores.
Buffer stock given in the units is the responsibility of nurses and they facilitate audits
as and when required
Return unused drugs and consumable
Central Sterile Supply Department (CSSD)
CSSD supports nurses by supplying all sterile items for the units.
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Items are either taken as stock or loaned from CSSD.
Nurses are responsible for ensuring proper storage and count of all CSSD items.
Radiology
Send requests through HIS appropriately
Take appointments before sending patients for ultrasound/CT/Carotid Studies
Inform once again before sending the patient for a test
Get someone ready to pick patient after investigation
X-ray films not reported to be sent soon after the doctor has seen them
Knowledge of necessary preparations for radiological procedures
Laboratory
Tests to be done should be indicated clearly in the forms and entered appropriately
in the system (Modified)
Check samples before sending for any clotted/inadequate sample etc.
Ask for the reports through HIS of tests done and inform doctor immediately after
receiving reports
Inform in advance to Lab person for collecting samples for biopsies/Mxt test
Write clearly the type of fluid/tip of lines/type of catheter when sending for cultures
Blood Bank / Blood storage
Give pre-information regarding blood demand
Send appropriate requests through system and double check on phone
Proper labeling – only stickers
Send samples of grouping and cross matching without delay
Know the protocol for blood returns in case of reaction
Send appropriate forms after administration of blood safely
Take consents for HIV tests.
Medical Records Department (MRD)
Completion of discharge/death files as per hospital standards
Dispatching files to MRD after ensuring proper arrangement of patient record)
Handling MLC files
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Information Technology (IT)
Support for Hospital Information System (HIS) and for Hardware
Human Resources (HR)
HR coordinates the recruitment of nurses.
Nursing works in close coordination with HR is respect to: Attendance, leave, service
bonds; monthly performance allowance, medical insurance, remunerations and staff
welfare.
6. Nursing Manpower planning
Nursing Manpower planning is done every year taking into consideration the following
I. The business growth plan of the unit
New Medical Programs
New Departments
New Services
II. The current manpower deployment versus the nursing norms
III. The projected Occupancy for the year to come
Nursing Norms
Fortis Nursing Norms are derived from various sources such as guidelines laid down by
NABH staffing guidelines, Indian Society of Critical Care Medicine guidelines for staffing of
critical care units.
S.No Department Manning Norms
1 Wards Ratio 1:6
2 Ots 2 nurses per OT in M and E shift, 3 nurses in the night

3 Cath Lab 2 nurses per Lab per shift
4 ICUs/Emergency/BMT/Transplant Ratio 1:1.25 -2

5 Labor Room 2 nurses per table per shift
6 Pediatric Ward Ratio of 1:2
7 OPDs 2 nurses per shift for POD of 25

8 Blood Bank 1(No Reliever)
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9 Clinical Instructor 1 per hundred nurses
10 Nurse educator 1(No Reliever)
Day Care
11 (IVF/Endoscopy/Urology/Cath
Recovery) Ratio 1:3
12 Infection Control Nurse 1 per hundred nurses
13 Nurse In Charges 1 per nurse station (No Reliever)
14 Supervisor I per 100 beds per shift or one per shift

15 DCNO 1 (No Reliever)
16 CNO 1 (No Reliever)
Staffing plan
The staffing is done based on occupancy and the required staffing ratios are maintained
round the clock through redeployment of staff in each shift by the shift-nursing supervisor
as and when required. Please Refer Acuity tool in Annexure I
Monthly Duty Roster
Purpose
To maintain required nurse patient ratios.
To ensure equal distribution of shifts to all staffs.
Each staff will get one weekly off every week. (Sunday – Sunday must reflect one off).
Every shift must have a proper mix of staff to ensure the required quality of care.
After long leave all the staff will be assigned to morning shift or evening shift only
Compensatory off will be given only if the supervisor justifies the extra duty Attendance
should reflect these accurately. After night duty an off is compulsory. None can come on
morning or evening. Nurse In charges to ensure that hard copies of duty rosters are
submitted to the Nursing office before the first of the next month after duly uploading it
into the system
Contingency Plan
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Purpose
To ensure sufficient manpower in the areas with deficient staff
Floater policy
Shift supervisors are responsible to float in and out of nurses in order to ensure all areas are
adequately staffed in quantity and quality. Unit In-charge/shift in-charge must send the staff
without delay to the directed Units.
The nurse who comes for help must introduce herself/himself to the Unit In charge/Shift in
charge.
The In charge will assign patients as per the capabilities and needs.
A brief orientation as to where to find what will be given by the In charge.
Medications will be always administered under supervision.
In charges will ensure that the nurse who is floated into his/her unit is relieved for the tea
and lunch breaks
In charges to ensure that the nurses are relieved at the end of the shift in a timely manner.
Calling off duty nurses
In time of acute surge in patient load, shift supervisor maintains Nurse patient ratio by
calling in nurses living locally or those living in staff hostel provided for by the hospital.
At times nurses continuing into the next shift due to sudden staff shortage caused by
unplanned leave are provided for with food and appropriate time back. This is done at the
discretion of the shift supervisor
Leave Policy
Purpose : To ensure effective utilization of staff to ensure safe nursing care.
Annual leave plan is made for a period of 12 months (April to March)
Annual leave plan will be submitted to Nursing Office in the first week of January.
The in-charge needs to start working on plan well in advance in conjunction with the
concerned ANS/supervisor, so that the leave plan permits only the no. of staffs that
could be on planned leave at one point of time.
The staffs who do no avail the leave as planned are not guaranteed annual leave at
another time of their convenience.
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Administration
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Leave plans once approved by NS/CNOs cannot be changed unless the NS/CNOs
approves it again.
Any extension of planned leave without a valid reason will be treated as leave
without pay.
Public holidays can be clubbed with planned leaves and the same must be
mentioned in the leave form as suffixed or prefixed.
Nurses availing planned leave must report to the nursing office before proceeding
for leave and on resuming duty.
All CL/SL etc. must be submitted for approval within 48 hrs of resuming duty;
otherwise they shall be treated as absent.
The responsibility of submitting leave application in time lies exclusively with the
employee
Ward In-charge, supervisor to oversee and ensure its adherence.
All In-charges will confer with area ANS/supervisor; for granting unplanned leaves
and get approval from HOD.
Casual Leaves, when a particular department is light, can be given only after
consulting ANS/Supervisor/HOD to ensure no staffing issues in other areas
Sick leave must be informed minimum 2 hours before starting of duty. The staff
when sick must report to OPD/ER as per the hospital protocol
Any leave for more than 2 days will need to be informed to HOD for approval
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Administration
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DEPARTMENTAL STRUCTURE (ORGANOGARM)
CNO/NS
DCNO/DNS
ANS/Supervisor ANS/Supervisor ANS/Supervisor

Nsg Services Nsg Education Nsg Services
Unit In-Charge
Clinical Patient
Shift In-charge (Sr. Staff
Instructors Educators
Nurse)
Staff Nurse
KEY RESPONSIBILITIES: Chief Nursing Officer

Title: Chief Nursing Officer /Nursing Superintendent
Nos: One
Qualifications: MSc / BSc / Diploma in Nursing Administration
Experience: Minimum of 2 years of experience as NS OR 3-5 Yrs as ANS
Reporting: Reports to Facility Director/ Medical Superintendent
Shift Timings: General Shift
Principal Duties and responsibilities:
Formation of nursing service Philosophy
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Formation of aims, objectives and policies of nursing services
Interviewing nurses
Prepares Budget for nursing service department.
Evaluate confidential reports and recommends staff for promotion.
Functions as a member of condemnation board for linen and equipments
Enforces implementation of hospital policies.
Investigates complaints and takes necessary steps.
Maintains discipline among nursing staff.
KEY RESPONSIBILITIES: DEPUTY NURSING OFFICER
Title: DEPUTY NURSING OFFICER
Nos: One
Qualifications: MSc / BSc / Diploma in Nursing Administration
Experience: Minimum of 2 years of experience as DNS OR 3-5 Yrs as ANS
Reporting: Reports to Nursing Superintendent
Assumes Nursing Superintendent’s responsibilities in her/his absence.
Key responsible areas will be assistance to all functions of CNO.
Any other additional responsibilities as designated by CNO.
KEY RESPONSIBILITIES: Assistant Nursing Superintendent
Title: Assistant Nursing Superintendent
Nos: As per hospital strength
Qualifications: B.Sc. / GNM / Diploma in nursing administration
Experience: 2 years experience on the similar position OR 3 Yrs as ANS
Reporting: Chief Nursing Officer

Assists in selection/requirement of nursing staff.
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Assists in planning and organizing the new units of hospital
Keeps records and reports of nursing services.
Helps in allocating nursing personnel to various nursing service department
Maintains confidential report and records of nursing staff of his/her area.
Participates in unit based quality management/ care improvement programs.
Organizes and plans nursing care activities of the department according to hospital
policies and service needs.
Coordinates and promotes relationship between nursing staff and other
departments.
Enforces and monitors adherence to standards of practice according to hospital
rules, regulations and policies.
Submits specific performance information for staff evaluation to Chief Nursing
Officer
KEY RESPONSIBILITIES: NURSING SHIFT SUPERVISOR

Title: Nursing Supervisor
Nos: As per areas
Qualifications: BSc / GNM
Experience: Minimum of 3 – 5 years of experience as a unit in-charge
Shift Timings: All three Shifts
Give complete and comprehensive report to the incoming supervisor and to NS as
per set guidelines
Arranges staffing as per need for the next shift and does changes during the shift
depending on workload in various units
Analyze and evaluate future staffing needs
Guides unit in-charge in planning and scheduling of work for nursing personnel &
GDA’s ensuring proper distribution of assignments and adequate manning
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Maintain liaison between nursing personnel and other departments to ensure
coordination for optimal patient care
Counsel unit in-charges, staff nurses in the development of professional skills
Maintain communication with patients, the families and other hospital staff to
ensure compliance with hospital administrative and nursing policies
Prepares and submits reports to NS/ANS as directed
Responds to all code blues and ensures patient care as per guidelines
Responds to emergency situation and resolves issues in consultation with
NS/ANS/MD as required
Responds to patient/family/staff grievances and addresses them in professional
manner upholding the organizational values
KEY RESPONSIBILITIES: CHARGE NURSE

Title: Charge Nurse
Nos: One per each unit
Qualifications: BSc /GNM
Experience: Minimum of 3 years of teaching / clinical experience
Prepares monthly duty roster, leave plans and Unit reports
Responsible for raising flag for requirement of Nursing buffer and reviewing patient
acuity in ICUs and other areas
Calculating and reviewing productivity metrics e.g. Nurse per occupied bed ratio etc.
Responsible for quality metrics and patient care metrics
Responsible for Supervision and implementation of efficient nursing care of
inpatients
Responsible for orienting new Joinees to the Unit and ensures completion of unit
orientation and finishes the check list
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Maintains the record of mandatory tests and in service attendance. Ensures filling of
nursing documents as per protocols
Conduct morning rounds of the unit. Take a account of any problem and resolve it.
Keep the ward stock replenished and ensure all items are accounted for.
Ensures upkeep of equipment of respective unit and promptly inform the Bio-Med/
Engineering department for repair of any defects in the equipments.
Attend monthly meetings and disseminates information to the rest of the team
members.
Should be present at the time of handover and make sure that patient assignments
are carried out appropriately.
Should inform hospital acquired infection, untoward treatment outcomes to the
infection control nurse.
Able to identify potential falls, pressure ulcers and guide staff accordingly
Ensures patient safety at all times from admission till discharge
Maintain departmental policies and able to intervene when not in compliance
Documents all incidents in record for reference for annual evaluations.
Discuss with patient / family any issue related to care.
Demonstrates effective management.
Able to manage and improvise in case of short supplies
Maintains confidentiality and record of the staff
Able to resolve staff complaints and ensures staff satisfaction.
KEY RESPONSIBILITIES: NURSE EDUCATOR

Title: Nurse Educator
Nos: One
Qualifications: MSc / BSc
Experience: Minimum of 5 years of teaching and 3 years of clinical exp.
Reporting: Nursing Superintendent
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Plans coordinate and conducts formal nursing induction program.
Makes monthly In-service Education Calendar and Induction Program details and
send it to all nursing and other concerned departments
Plans coordinate and conduct variety of in-service education program.
Modify and update existing educational programs when appropriate.
Impart continuing education through mini workshops, re-demonstration of skills &
mini quiz etc.
Assist in making nursing protocols, modify and update the existing protocols
Maintain liaison with training department in planning seminars, workshops,
educational programs and related activities
Keep records and reports of all trainings and send the monthly report for the same
to the HOD
Help the HOD for planning, organizing and conducting nursing certification programs
Keeps abreast of new developments in training techniques, methods and programs
Liaise with other departments in planning, seminars, workshops and other related
activities
Assist in preparing budget for teaching and training aids
Contribute in nursing and medical research endeavors
Productive member of Nursing Quality Improvement Committee and a member of
any other committees as directed by superiors.
KEY RESPONSIBILITIES: CLINICAL INSTRUCTOR
Title: Clinical Instructor
Nos: One per 100 nurses
Qualifications: M.Sc./BSc
Experience: Minimum of 2 years of teaching / clinical experience
Reporting: Nurse Educator
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Facilitator in the induction program & ensure that all staff of her unit have
undergone induction.
Assess & identify any learning need of staff in her area & then plan with Nursing
Educator to organize & execute retraining for them.
Assists Nursing Educator in making protocols, care plans & audit checklists.
Gives incidental teachings on rounds & demonstrate skills whenever appropriate.
Conducts code blue drills.
Keeps a record of in-service attendance of staff & motivate those with less
attendance.
Assists Nursing Educator in conducting practical exams for trainees.
Coordinates with Dr’s for in-service classes
Executes training programs for nurses.
KEY RESPONSIBILITIES: PATIENT EDUCATOR
Title: Patient Educator
Qualifications: M.Sc./BSc
Experience: Minimum of 2 years of clinical experience
Reporting: Nursing Educator
Visit all patients at different times of the day.
Ensure pre-op & post-op to all patients
Give incidental teaching to patients, their relatives as appropriate during rounds
Present lectures and trainings to a group or individuals as appropriate
Prepare educational material for clients as appropriate in consultation with the
specialists
Evaluate programs as and when required
Take return demonstration from clients
Involve/educate staff nurses on health education as and when required
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Document all health educations given
Liaise between clients and medical team for any clarification/educational needs of
any clients
KEY RESPONSIBILITIES: INFECTION CONTROL NURSE
Title: Infection Control Nurse
Qualifications: GNM/BSc
Daily visits to all wards and patient holding units.
Collection and tabulation of daily data of all incidents of hospital acquired
infections
Collection of needle stick injury incidents and assisting Infection control team in PPE
Ensuring that samples of blood, stool, sputum, urine, swab, when indicated are
collected and dispatched to the laboratory on time.
Initiating hospital infection control form while documenting for nosocomial
infections.
Computation of ward wise or procedure wise statistics
Daily visit of laboratory to ascertain results of previous days’ sample
Warning treating doctor on any positive cultures
Monitoring and supervision of infection control practices among hospital staff.
Training of nurses and paramedical personnel on Infection Control policies and hand
hygiene
Conducting educational activities related to infection control practices for
housekeeping and nursing aids.
Assist in bacteriological studies of all cases.
Conducting infection control quiz.
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KEY RESPONSIBILITIES: QUALITY NURSE

Title: Quality Nurse
Qualifications: MSc/BSc
Conducts incident, investigations including root cause "near miss "and sentinel
event.
Performs Core Measure abstraction and data analysis, prepares reports for Chief
Nursing Officer, Quality Assurance Department and Accreditation Bodies.
Assists the Chief Nursing Officer and Quality Head in developing and/reviewing
forms used for medical records, ensuring compliance with all regulatory agencies
and accreditation bodies and/or policies, protocols and standards
Provides information, training, guidance and support for ensuring quality and
adherence to accreditation standards in the nursing team
Acts as staff and/or participating member of various committees; participates in
Nursing and Physician staff meetings for information gathering and consultation
KEY RESPONSIBILITIES: GENERAL NURSE

Title: General Nurse
Experience: Minimum of 1 year of clinical experience
Reporting: Charge Nurse/Area ANS
Shift Timings: All three shifts
Compliance of nursing manuals/protocols at all circumstances while on duty
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Following medical prescriptions/orders and taking care of patient’s need
Taking care of minimum housekeeping standards including related departmental
interface.
Complete hand over/take over of her assigned patients including physically checking
patients and their units.
Checks her special assignments like checking of crash cart, checking inventory, or any
other assignment given by in-charge
Plans, organizes, and delivers nursing care in a manner that upholds organizational
values, healing, promotion of health and prevention of complications
Maintenance of nursing records including nurse’s notes, charts, consents, and initial
assessment data for all assigned patients as per protocols.
Maintains continuity of care through clear and concise verbal and written
communication with all departments, internal and external customers
Reception and orientation of newly admitted patients assigned to him/her.
Collects and sends all relevant documents duly completed to ensure speedy
transfers or discharge process. Will accompany all critical & helpless patients.
Performs nursing procedures as per set protocols in the department
Imparts relevant health education to patients and families and documents of the
same.
Takes care of all dying patients, maintains seriousness and accompanies every dead
body to the mortuary.
Attends all in-service education programs and takes mandatory certification
programs.
Takes responsibility and accountability in professional advancement.
Specific Responsibilities towards Geriatric Patients:
Should understand psychological changes and emotional needs of an elderly.
Should be able to do assessment of all systems and must have knowledge of
physiological changes when aging.
Should be able to understand and provide safety and security needs to the aged.
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Should be able to explain events and procedures in concise, simple and
understandable language.
Be able to reduce anxiety and agitation
Must be a patient listener
Be able to promote independence in self-care activities.
Should be able to assess intake and urination patterns and should be able to provide
appropriate clothing to facilitate toileting.
Specific Responsibilities towards Pediatric Patients:
Should use skills that eliminates or minimize the psychological and physical distress
experienced by children and families.
Must make parents aware of all available health services, information of treatments
and procedures and encourage changing or support existing health care practices.
Be able to identify growth and development needs as per age of the child
Be aware of safety measures to be adopted for children during treatment in hospital.
Restorative role, which includes restoration of health through care giving activities.
Coordination/collaboration with member of health team
KEY RESPONSIBILITIES: CARDIAC OT NURSE

Title: COT
Experience: Minimum of 1 year experience in Operating room
Reporting: Area ANS Charge Nurse
Shift Timings: All Shifts
Takes complete hand over of patients received in OT or any patient in post-op area
Checks her assigned OT for complete carbolization and readiness for surgery
Ensures that the OT is uncluttered and clean at all times
Ensures that all surgical specimens are sent as per protocol.
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Accompanies consultants/SR on rounds.
Ensures that information regarding any issues including wrong count is of primary
concern and should inform the OT in charge without delay.
Informs in charge without any delay in supplies that are about to finish to help in the
smooth running of the unit.
Informs in charge of any breakage, faulty equipment etc: without delay
Returns all unused medications/consumables to stores before sending the billing
activity.
Ensures timely and accurate entries in BA (manual and HIS) at all times.
Informs any requests for leave duties to in charge in writing before the 20th of every
month
Checks all documentation (nurses note, charts, consents, patient data) for its
completeness
Maintains continuity through clear and concise verbal and written communication
with all departments, internal and external customers
Assists in transfer of post op patients in a safe and efficient manner. Follows
guidelines laid in protocols
transfers or discharge process. Will accompany all critical & helpless patients
Imparts relevant health education to patients and families and documents the same
programs
Plans, organizes, sets up surgical trolley, anticipates needs of surgeon and performs
surgical counts, disposal of waste as per protocol
Always behaves in a manner of upholding organizational values, promoting health
and preventing complications
Floats as a helper to other areas as and when directed by superiors
KEY RESPONSIBILITIES: MULTISPECIALITY OT NURSE
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Title: MSOT
Qualifications: GNM/Bsc
Experience: Minimum of 1 year experience in Operating room
Shift Timings: All Shifts
Principal duties and responsibilities:
Takes complete hand over of patients received in OT or any patient in post-op area
Checks her assigned OT for complete carbolization and readiness for surgery
Ensures that the OT is uncluttered and clean at all times
Ensures that all surgical specimens are sent as per the protocol.
Accompanies consultants/SR on rounds.
Ensures that information regarding any issues including wrong count is of primary
concern and informs the OT in charge without delay.
Informs in charge without any delay in supplies that are about to finish to help in the
Informs in charge of any breakage, faulty equipment etc: without delay.
activity.
Informs any requests for leave duties to in charge in writing before the 20 th of every
month
completeness
Assists in transfer of post op patients in a safe and efficient manner. Follows
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programs
Always behaves in a manner of upholding organizational values, promoting health
and preventing complications
KEY RESPONSIBILITIES: ICU NURSE
Title: Intensive care unit
Experience: Minimum of 1 year experience in ICU
Shift Timings: All Shift
Maintenance of nursing records including nurse’s flow sheet, charts, consents, and
initial assessment data for all assigned patients as per protocols.
Maintains continuity of care through clear and concise verbal and written
communication with all departments, internal and external customers
Reception and orientation of newly admitted patients assigned to him/her.
transfers or discharge process. Will accompany all critical & helpless patients.
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same.
programs.
Takes responsibility and accountability in professional advancement.
Updates herself in special skills from time to time.
Educates herself on any new equipment installed in her unit.
KEY RESPONSIBILITIES: CATH LAB NURSE
Title: Cath. Lab
Experience: Minimum of 1 year experience in Cath. Lab
Shift Timings: All shifts
Takes complete hand over of patients received in Cath Lab
Checks her special assignments like checking of crash cart, taking inventory, or any
other assignment given by in-charge
Checks assigned Cath lab for complete carbolization and readiness for procedure
Ensures that the Cath Lab is uncluttered and clean at all times
Ensures that all samples are sent as per protocol.
Assists consultants/SR during procedures as per protocol
Ensures that information regarding any issues is informed to unit in charge without
delay.
Informs In charge of any delay in supplies that are about to finish to help in the
Informs in charge of any breakage, faulty equipment etc: without delay.
activity.
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Informs any requests for leave duties to in charge in writing before the 20 th of every
month
completeness
Assists in transfer of post procedure patients in a safe and efficient manner. Follows
Imparts relevant health education to patients and families and documents the same
programs
Always behaves in a manner upholding organizational values, promoting health and
preventing complications
KEY RESPONSIBILITIES: Chemotherapy Nurse
Title: Chemotherapy Nurse
Nos: As per bed strength
Experience: Minimum of 1 year experience in Oncology
Reporting: Deputy Chief Nursing Officer/Area ANS
Shift Timings: Morning/ Evening/General
Assumes responsibility for the complete management of oncology patients
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Function as an interface between patients, Oncologists, staff nurses and others
involved in patient management.
Designs and maintains chemotherapy patient records which enhance
communication and continuity of care.
Designs orientation tools/programs for nurses in management of oncology patients,
in consultation with NS oncologists and hospital management.
Actively participates in empowering the staff with knowledge and skill in oncology
nursing by conducting lectures, discussion and demonstration.
Responsible for providing guidance and counseling to the staff in their dealing with
oncology patients.
Assures overall responsibility of indenting, storage and safe administration
chemotherapy agents.
Responsible for providing relevant education and counseling to oncology
patients/family members.
Identifies areas that require staff development initiatives in the delivery of nursing
care of oncology patients.
Collaborates with other departments in development of orientation activities in the
management of oncology patients.
Promotes nursing research by initiating and participating in different programs.
Monitor and evaluate cost effective and safe nursing practices, recommending and
implementing changes as required.
Collects, complies and disseminate statistics of oncology patients.
7. On Boarding of New Joiners
Objectives
To familiarize a new nurse with
Various departments of the hospital
The unit he/she will be working
Organizational policies and protocols
The line of communication
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Soft Skills
Expected professional behavior
Operation of Equipment
Computer Training
Induction program is planned every month & is scheduled in the In-service Calendar
It consists of
Theory sessions -12 days
Unit Orientation -15 days
On the job training involves working with a Mentor .The nurse may be assigned
responsibilities under supervision – 30- 60 days
After being granted privileges the staff is assigned independent responsibilities - 90 days
Competency Assessment – after 6 months
Nursing Induction Program
This induction program is intended to structure the transition of novice nurse to competent
nursing professional
Purpose:
To provide basic orientation to novice staff nurse about Hospital physical structure,
organogram, SOPs etc.
To provide Skill based training to improve area specific competency
To develop soft skills through Service excellence training
To provide training about Hospital Information Service
Nursing Induction Program includes
Classroom Induction Training: HR Induction, Nursing classroom Induction
Service Excellence Training
On The Job Training
Classroom Induction Training:
Every new joined nurse undergo classroom induction training which are conducted
by Human Resource (HR) Department and Nursing Department
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HR Induction: It is conducted by HR team as well as respective team members such
as Infection Control Nurse (ICN), Safety Officer and Quality Officer Etc. It is 16 hours
program followed by the written test.
It focuses on:
Orientation to Fortis Healthcare
Organogram of complete Hospital
Scope of Services provided in the Hospital
Facility Round
Employee Rights and Responsibilities
Duty Timings, Leave management through Software
Process of obtaining Salary Slip, Income Tax related formalities
Medical benefits available to Nurse and family
Employee Vaccination
Performance Appraisal
Grievance policy
Prevention of Sexual Harassment Policy
Disciplinary measures
Safety Codes and preparedness including Fire Safety
Hospital Infection Control and Biomedical Waste Management
Basic Life Support
Quality Indicators, Service Indicators, NABH Accreditation
Incident Reporting process
Care of Vulnerable patients
Organizational Initiatives such as Sparkle
Nursing classroom Induction
It is conducted by Nurse Educator, Charge Nurses, ICN and senior staff nurses. It is 11 days
program, that include following topics
Organogram of Nursing Department
Rules and regulations about Nursing Hostel
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Important Contact Numbers
Uniform policy, Grooming
Duty Rota, Assignment books
Patient Identification
Nurse Patient Communication, Nursing Care Bundle
Medication Safety : Safe drug Administration, High Alert Drugs, LASA Drugs,
Concentrated Electrolytes, Narcotics policy and Drug Calculations
Practical Training of Drug administration
Patient Safety: IPSG Goals
Fall prevention
Restraint policy
Prevention of Hospital Acquired Pressure Ulcer
Nursing processes such as : Admission, Discharge, Transfer
Initial Nursing Assessment and Reassessment
Patient’s Medical Records Documentation
Safe use of common biomedical equipments
Hospital Information System: Drug Indent, Diagnostic Test entry, Electronic Patient
Record Checking, etc.
Pharmacy processes
Imaging processes
Laboratory Investigation processes
Code Blue Policy and CPR Training
Skill Based Training : IV Cannulation and Safe Infusion Practices
Sample Collection for Culture test
Nursing procedures such as: Vital Signs monitoring, Nasogastric Tube Insertion and
Nasogastric Feeding, Nebulization, Steam Inhalation, 12 lead ECG
Preoperative care and Post-operative care
Prompt answering of call bells
Importance of various Inventory books. Daily Billing Activity
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Addressing Patient Concern and feedback, prompt escalation of concerns
These trainings are followed by written test
This training is conducted by Nurse Educator as well as HR team members. It Focuses on
Nurse patient interaction
On The Job Training (OJT)
This is an area specific structured plan for novice nurse to develop competencies.
It is based on SOP of the unit, specific Nursing skills, documentation etc that needs to
be developed.
It is conducted by Charge Nurses and Senior Staff Nurses/clinical instructors.
Duration is One month but it may need to be prolong depends on competencies
developed by the respective novice nurse.
Here the novice nurse starts working in the assigned department according to the
privileging. The necessary hands on training and assistance are provided by Charge
Nurse and senior staff nurse.
The Nurse Educator monitors the progress of On the Job Training. Competency test
is conducted at the end of six months. The Charge Nurse provides feedback to staff
nurse.
555 Checklist is a structured regular follow up checklist used by Chief Nursing Officer
to interact with new nurse about their experience in the hospital, hostel and
induction activities
8. Performance Standards (for new joiners)

Purpose
To ensure that all new nurses are inducted and assessed via common tools for assurance of
minimum entry level competence.
Policy:
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The new nurse will be under probation for 6 months. During this time she/he is expected to
complete all requirements as listed in the table below in order to be eligible for
confirmation.
S. No Elements Time Frame Resp.
1 Find it yourself Checklist 2 Days After joining Unit I/C
15 days to 45 days (Depending on
2 Unit Orientation –New Staff stipulated period as fixed by the Unit/CI
unit)
3 Induction Record 14 Days (During Induction) NE
4 Induction Checklists 90 Days CI/Unit I/C
5 Assignment Record 60 Days CI
6 Competency Assessment 1 month, 5 Months CI/Unit I/C
Pass Infection Control Test
8 90 Days Self
(> 60%)
Pass Nsg. Protocol Test (> Self
9 90 Days
60%)
9. Monthly Performance Assessment (NQIP)

Purpose
To ensure that standards of nursing are maintained.
Policy
The Monthly Performance Assessment, based on observed behavior/conduct of the
employee.
The following principles would govern the administration of Monthly Performance
Assessment
The team members would be judged on the following criteria:
Late comings/Early goings
Grooming
Conduct
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Customer Orientation
Absenteeism
Late comings
The team members would be expected to be on their work place in time.
Time discipline would be noted for each team member.
Absenteeism
Regular attendance, no leave without pay, leaves planning in advance and with sufficient
notice would be encouraged.
Customer Orientation
The issues related to patient care, attitude of team members towards the patient,
responsiveness, proactive ness, complaint redressal would be looked into.
Conduct and Discipline
The general conduct, including team play, towards superiors, peers, other departments,
record maintenance, quality of work, imbibing and display of organizational values and
culture etc would be taken into account under this head.
Grooming
This would take into account the dress, attire and grooming. Team members are expected
to adhere to all points given in grooming standards as prescribed including maintenance and
wearing of neat and clean uniform, shoes, hairdos as prescribed (shaving for males),
jewellery as prescribed, body odor etc
The area in charge would be required to keep a record of each of these criteria. The
following would be the format for recording the data for each team member.
S.No Criteria 1 2 3 4 Remarks
1 Late coming
2 Absenteeism
3 Grooming
4 Customer Orientation
5 Conduct
The scoring is to be done as given below:

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a. Late comings
No late coming would earn 4 points
One-two late comings would earn 3 points.
Three-Four would get 2 points
Five or more than five would get 1 point.
b. Absenteeism
No absenteeism would earn 4 points.
Even one day less (Without pay/ absent without intimation) would earn just 1 point.
c. Grooming
If no aberration is noted as per grooming/uniform policy (already in place), there
would be four points.
1 incident – 3 points, 2 incidents – 2 points & more than 2 incidents just 1 point
d. Customer Orientation
If no adverse incidents related to patient care are reported, there would be 4 points.
1 incident – 3 points, 2 incidents – 2 points & more than 2 incidents just 1 point.
e. General Conduct
Similarly, for conduct, if no adverse incident is recorded, there would be 4 points,
one incident-3 points, two incidents-2 points and more than two incidents-just 1
point. The maximum possible score (MPS) would be 20. The area in charge would be
required to be very judicious in rating and must record specific instances on a daily
basis. In the remark column, the incidents would require to be recorded
10.In-Service Education
This program is intend to update the knowledge and practices of nursing professionals
Purpose
To provide trainings based on training need analysis
To ensure all nursing team members are updated with reviewed SOPs
To ensure adequate nursing team members are trained to provide (ACLS) Advanced
Cardiac Life Support
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To ensure adequate nursing team members are trained to provide Pediatric
Advanced Life Support (PALS) and Neonatal Resuscitation
To provide training on Safe and effective use when any new biomedical equipment
is introduced
To provide Skill based training when any new product is introduced such as IV
cannula etc.
To provide guidelines before implementing any new medical record document or
change in format
To reorient the nurse about knowledge and practice when change of department
and change of responsibility is done
Continuous Nursing Education Program includes-
Daily afternoon class
Area Specific Training
Orientation Training for Change of Department
Orientation Training for Change of Responsibility
Daily afternoon class
Daily class is for all evening shift nursing team
Training Calendar is rolled out at the beginning of the month
These classes include topics based on training need analysis and mandatory training
topics
Training of staffs done when new equipment are introduced in the system
Area Specific Training
It focuses on specific nursing procedures carried out in the unit
It also focuses on type of nursing care provided in the respective unit
As per training need analysis , if any one unit has certain training needs accordingly
focused sessions are conducted
It is driven by charge nurse
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The modules are:
Patient First
LEAP
Corporate grooming
Telequettes
Email Etiquettes
Orientation Training for Change of Department
The Nurse who is posted to a new department undergoes On the Job Training for
his/her new department
Orientation Training for Change of Responsibility

For up gradation/change of responsibilities:
The nurse will undergo training module that include the necessary domain
knowledge, skill development, clinical experience from the respective expertise
The concerned immediate supervisor will assess the competencies and if necessary
further training needs will be provided
Training Need Analysis

This ensures review of patient care provided by nursing team and there training needs. It
also provide the structure for Corrective and preventive actions for incidents that occur due
to training deficiencies
Responsibility: Nurse Educator, Charge Nurses and Chief of Nursing
Purpose:
To identify specific training needs of nursing team
To incorporate nursing outcomes in the continuous nursing education program
To divide training topics as per need such as training for entire team and trainings to
specific units
Nurse Educator takes account of following aspects while analyzing training needs
Patient’s feedback
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Consultant feedback that indicate training needs of nurses
Staff score in the monthly performance assessment (NQIP) done by their immediate
supervisor
Incidents such as medication errors, patient’s fall, and hospital acquired pressure
ulcer etc.
Incidents of Hospital Acquired Infection
Process and Outcome Audits such as Medical Records Audit, Audits conducted by
Infection Control Nurse (ICN), Clinical Pharmacist etc.
Observations of mock drills of safety codes and Code Blue
Reports of SOP Compliance audit
Introduction of any new practice/ software for Patient care or Employee Service
Competency Assessment tests and Quarterly test score
Structured Training Need Feedback from Charge Nurse (Please refer Annexure II)
Effectiveness Check
Training is validated through skill verification and subsequent certification as
applicable or evaluator tests
Training certificates and skill verification practical re-demonstration on the job
11.Nursing Empowerment
Chief Nursing Officer is the driving force for nursing Empowerment. Every Nurse is
empowered to take decisions about patient safety and recovery. Doctors and other
departmental personnel are always approachable and follow teamwork approach. Nurses
are empowered to inform patient’s condition to Consultants directly.
Early Warning Score Assessment, Safety codes are placed to handle medical emergencies
like cardiac arrest and stroke. Innovation is encouraged by nurses to improve patient care
and safety, quality, process improvement and service timeline. Nurse driven quality
improvement projects are conducted. Charge nurses, clinical instructors, senior staff nurses
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are members of all important hospital committees. Planning of training calendar is done
with active involvement of nurses.
Structured program exists for enhancing clinical competency and leadership skills of nursing
professionals; as knowledge is the basic requirement to exercise empowerment of the team
12.Shift Handover/Endorsement
Purpose: To ensure continuity of care
A structured shift hand over is done among assigned nurses in the units also
amongst shift supervisors
Shift hand over communication is based on communication guideline of SBAR (
Situation, Background, Assessment, Record)
It is documented at every shift change and signed off by both duty staff nurses
Shift handover involve active participation of patient, whenever possible
Charge Nurse or senior staff nurse monitors the complete shift handover is carried
out and essential information is handed over effectively.
Formats of Endorsement guideline and documentation can be referred in Annexure
III and IV.
13.Nursing Audits
Objective
To ensure that our clients get care with the accepted International standards
Nursing Audits are conducted to evaluate the services provided to our clients. The results of
these audits are then compared with the accepted standard checklists that we have.
Training and re-audits are done if required to ensure that the care provided by our nurses
meet the client’s need and according to the established standards. Following are a few of
the audits-
Infection Control Audits
Nursing Process compliance audit
Nursing Care Bundle audit
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HAPU prevalence audit
Patient and Unit Safety audit
Medication safety audit
Crash cart audit
Nursing Quality and Patient Safety
We believe that quality improvement is an on-going process and as the front line deliverers
of patient care, we have a major and responsible role to play in improving and maintaining
quality care to patients and families.
We also believe that improving and maintaining quality of nursing personnel is equally
important to achieve the above.
We believe that constant efforts to work hard in hand with other services to achieve the
above are equally crucial and all efforts will be made to achieve the organizational goals.
Goal
Nursing Quality Improvement Committee (NQIC) aims to ensure that a constant process is
undertaken so that all the patients and families leave Fortis with a positive experience and
to prepare nurses adequately for the said role based on regular monitoring, auditing,
counseling and evaluation.
Objectives
Develop nursing sensitive quality indicators
Develop tools to measure the outcomes
Evaluate monthly and plan and implement corrective actions
NQIC would also be responsible to meet with staff who have low performance levels,
attitude problems etc. For this purpose only the HOD, ANS/Supervisor and
concerned unit in-charge will meet the staff for counseling session.
The counseling session would be documented in the staff diary with the signatures
of all members.
NQIC meeting is part of monthly unit in-charges meeting. ANS / Sr. Nsg Supervisor to
ensure presence of deputed members as indicated
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The NQIC will concentrate initially on the frequently detected problem areas in the
department.
NQIC will gradually work toward establishing indicators and establishing
methodologies at par with international hospitals.
NQIC will be responsible for educating all nursing staff on the quality improvement
activities.
NQIC will educate unit in-charges to initiate their own quality improvement activities
in their respective areas.
NQIC will ensure active participation in the Quality improvement program of the
hospital.
NQI committee will consist of
Chairperson: Chief Nursing Officer
Coordinator: Deputy Chief Nursing Officer
Members (Permanent): All unit Charge Nurses
Members: Deputed staff (3)
NURSING QUALITY INDICATORS
The following quality indicators are adopted by department of nursing as per guideline laid
by international Nursing bodies
1. Pressure Ulcers:
The incidence of pressure ulcers would be less than 4 among all ICU patients. The measure
would be computed as:
Number of patient with Hospital Acquired Pressure Sore X 1000
Total no. of patient days
The incidence of pressure ulcers would be 0% in all other patients.
All patients received with pressure ulcer from outside will exhibit improvement in the level
of their ulcer.
2. Patient Falls
The rate per 1000 patient days at which patients experience an unplanned descent to the
floor during the course of their hospital stay. The measure would be computed as
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Total No. of patient Falls X 1000
Total no. of patient days
3. Patient Satisfaction with Pain Management
A measure of patient perception of the hospital experience related to satisfaction with pain
management.
Definition: Patient’s opinion of how well nursing staff managed their pain as determined by
scaled responses to a uniform series of question designed to elect patient views regarding
specific aspects of pain management. The questions would be administered to a sample of
all patients admitted to the hospital. All surgeries requiring more than 3 days of hospital
stay.
4. Patient Satisfaction with Educational Information:
A measure of patient perception of the hospital experience related to satisfaction with
patient education.
Definition: Patient opinion of nursing staff efforts to educate their regarding their
conditions and care requirements as determined by scaled responses to a uniform series of
questions designed to elicit patient views regarding specific aspects of patient education
activities. The questions would be administered to a sample of all patients admitted to the
hospital for acute care services. Necessitating more than 3 days of hospital stay.
Patient Satisfaction with Nursing Care
A measure of patient perception of the hospital experience related to satisfaction with
nursing care.
Definition: Patient opinion of care received from nursing staff during the hospital stay as
determined by scaled responses to a uniform series of questions designed to elicit patient
views regarding satisfaction with key elements of nursing care services. The questions would
be administered to a sample of all patients admitted to the hospital for acute care services.
Hospital Acquired Infection:
List of Hospital Acquired Infection and measure to calculate rates are:
CLABSI: Central Line Associated Blood Stream Infection
No. of CLABSI X 100
Number of central line days
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CAUTI: Catheter Associated Urinary Tract Infection
No. of CAUTI X 100
Number of catheter days
VAP: Ventilator Associated Pneumonia

Number of ventilator daysX 100
Number of Patient Days
SSI: Surgical Site Infection
Number of SSI cases X 100
Total number of surgeries
NSI: Needle Stick Injury, Sharp Injury
Number of incidents of exposure to blood & body fluids reportedX 100
Number of patient days
Hand Hygiene Compliance:
Total number of acts of hand hygiene when the opportunity existed X 100
Total number of hand hygiene opportunities
5. Nurse Staff Satisfaction
Job satisfaction expressed by nurses working in hospital settings as determined by scaled
responses to a uniform series of questions designed to elicit nursing staff attitudes toward
specific aspects of their employment situations. The questions would be administered to all
RNs in direct patient care or middle management roles at the institution.
14.Nursing Patient Safety Goals

Goal: Improve the accuracy of patient identification.
Use at least two patient identifiers (neither to be the patient’s room number) whenever
administering medication or blood products; taking blood samples and other specimens for
clinical testing, or providing any other treatments or procedures.
Goal: Improve the effectiveness of communication among caregivers.
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For verbal or telephone orders or for telephonic reporting of critical test results, verify the
complete order or test result by having the person receiving the order or test result “read
back” the complete order or test result.
Standardize a list of abbreviations, acronyms and symbols that are not to be used
throughout the organization.
Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and
the timeliness of receipt by the responsible licensed caregiver, of critical test results and
values
Goal: Improve the safety of using medications.
Remove concentrated electrolytes (including, but not limited to, potassium chloride,
potassium phosphate, sodium chloride>0.9%) from patient care units.
Standardize and limit the number of drug concentrations available in the organization.
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the
organization, and take action to prevent errors involving the interchange of these drugs.
Encourage reporting of all medication errors and complete analysis of errors where
indicated
Goal: Improve the safety of using infusion pumps.
Ensure free-flow protection on all general-use and PCA (patient controlled analgesia)
intravenous infusion pumps used in the organization.
Goal: Reduce the risk of health care-associated infections.
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene
guidelines.
Manage as sentinel events all identified cases of unanticipated death or major permanent
loss of function associated with a health care-associated infection.
Goal: Accurately and completely reconcile medications across the continuum of care.
Current medications upon the patient’s admission to the organization and with the
involvement of the patient. This process includes a comparison of the medications the
organization provides to those on the list.
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A complete list of the patient’s medications is communicated to the next provider of service
when it refers or transfers a patient to another setting, service, practitioner or level of care
within or outside the organization.
Goal: Reduce the risk of patient harm resulting from falls.
Assess and periodically reassess each patient’s risk for falling, including the potential risk
associated with the patient’s medication regimen, and take action to address any identified
risks.
FALL PREVENTION
PREAMBLE:
While it could be argued that all patients are at some degree of risk of falling during
hospitalization, some patient characteristics have been identified as being associated with
increased risk of falling. These include age, mental status, a history of falling, medications
impaired, special toileting needs and some medical diagnosis.
PURPOSE:
To achieve and maintain 0% fall incidents in the hospital
FALL PREVENTION INTERVENTIONS
ASSESSMENT
All patients will be assessed at the time of admission for risk of falling, receiving transfers
The “PTF” (potential to fall) precaution will be maintained throughout hospitalization except
those who have been put in the category for being in ICU’s. However universal fall
precautions will be continued for ALL PATIENTS
EDUCATION
Educational activities will be part of the fall prevention program and will be as follows:
Staff training to increase awareness of high-risk patients and prevention strategies
All nurses will be familiarized with the fall prevention program and evaluated
through a test and have to score equal to or more than 60%.
Educating the patient and family about the risk of falling, safety issues and their
mobility limitations. The same will be documented in patient records.
Teaching patients to make position changes slowly.
Orienting all patients to their bed area, ward facilities and how to get assistance.
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Explaining the use of grab bars in toilets to all patients
Reinforcing education to all high risk patients on a regular basis (every shift) and on
transfer between two wards
ENVIRONMENTAL ISSUES
Activities that aim to reduce environmental risks include:
Decreasing obstacles and clutter
Night-lights at bedside and toilet
Stabilizing beds and bed side furniture
Having grab bars near toilets
All repairs to be attended without delay
ELIMINATIONS
Interventions to support the patient’s elimination needs include:
Placing patients with urgency near toilets
Checking patients who are receiving laxatives and diuretics
Toileting at risk patients routinely (offering bed pan and urinal at regular intervals)
Instructing male patients prone to dizziness to sit while urinating
If need to stand, ensure someone is there with the patient
MEDICATIONS
Activities related to medication include:
Receiving prescribed medications along with doctor
Checking patients receiving laxatives, diuretics, antihypertensive etc.
Limiting combination of medications when possible (eg: sedatives, analgesics etc.)
MOBILITY
Interventions related to mobility:
Non-skid footwear
Providing physiotherapy
Instructing patients to rise slowly
Assistance while walking for “PTF” patients
Repeating activity limitation instruction to patient and family
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Assisting “PTF” patients during transfer
Assisting “PTF” patients to increase mobility by walking patients in corridor once or
three per shift if there is no medical contraindication.
MENTAL STATE
Altered mental status is one of the common identified risk factor for fall and the
intervention includes:
Reorienting confused patients
Orienting patients to the hospital environment
Moving confused patients near nurse’s station
Using family members to sit with confused patients
BED REST
Interventions that aim to reduce the risk of falling while patient is in then bed include:
Ensure bed is in “Low” position
Ensure bed brakes are on
Ensure bed side rails are in “UP” position
Ensure patients can reach necessary items
WHEEL CHAIRS & CHAIRS
To prevent fall involving wheel chairs include:
Use safety straps or seat belts in chairs
Ensure support to prevent slipping from chairs
Selecting suitable chairs for sitting and ensure appropriate height for transfer
MISCELLANEOUS
Use “PTF” stickers or charts
Seek help from physical therapy
Involve family in care
Warning all staff concerned on “PTF” status
Reassuring staffing needs in relation to high risk patients
All patients will be nursed under universal fall precautions.
All patients are considered to carry a risk of fall during hospitalization
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General Interventions are:
The beds will be always maintained at a “LOW” position except for procedures
needing higher heights of bed
N.B: When the need is over, the nurse must ensure that the bed is returned back to
“Low” position.
All the side rails must be in “UP” position all the time.
The assigned nurse will ensure that the call bell is within reach at all the times. The
return demonstration from patient will be takes on admission and on transfer
The patient and family will be oriented to the needs of keeping the side rails “UP”
The bedside of the patient will be maintained uncluttered at all times by the
assigned nurse
The foot stool will be placed at the right place to facilitate patient’s getting down
from bed
The brakes of beds, wheel chair and trolleys will always be kept locked
All patients will be visited hrly by the assigned nurse
The high-risk patients will be identified as per the assessment tool (Nursing
Admission/Assessment Form)
All critically ill patients are automatically placed under the category (PTF: Potential to
Fall). If the score is less than 7 the counseling will be documented in the approved
format by the doctor on duty and witnessed by the assigned nurse. (Fall risk
counseling form)
One Attendant will be allowed with the patient at all times except in the critical care
areas.
Assessment potential to fall will be noted prominently in the care records.
In assessment PTF will be noted in the daily worksheets of all units.
The patient and family will be educated especially as the preventive measures and
the same documented in the nurses notes.
If patient or family insists in violating the precautions the same will be documented
in the medical records
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The patient with “PTF” identified will not be allowed to move out of bed without
supervision of a nurse.
These patients will never be left alone in the toilets, even if the patient insists to be
left alone.
All “PTF” patients will be transferred only if the attendant is present.
All “PTF” patients will be especially checked before settling at night:
Check the side rails are “UP” position
Check the breaks of bed are locked
Check the call bell is working and within reach
Check if the patient/family knows how to use the call bell
Ensure all required items are in place
Reinforce need to call nurse for any requirements during night especially;
elimination
EVALUATION OF FALL PREVENTION INTERVENTIONS
Monitor and record all patient falls
Evaluate the situation that led to fall and suggest changes
Implement changes and modifications to the program in response to evaluations\
15.STATUTORY OBLIGATIONS
CONSUMER’S PROTECTION ACT - Implication on Nursing Practice
Consumers of health care are increasingly demanding to have a say in matters affecting
their health care. As consumers have become more aware of their rights, conflicts between
patients, health care professionals and institutions have developed. Nursing is affected by
this kind of situation in which nurses are also expected to answer questions, explain
procedures and respect the rights and requests of the patient. Nurses are challenged to
become advocates for clients.
The Consumer Protection Act enacted by the Parliament in 1986, has been drastically
amended and its scope greatly widened by the amendment of 1993. The Act now covers all
kind of services an all kinds of consumer transactions whether made in cash or in kind. It
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protects the consumer form the burden of restrictive and unfair trade practices and enables
the consumer forums and commissions to award compensation not only for monetary loss
in purchasing defective material or in hiring deficient services but also for mental pain,
suffering and harassment caused by defective goods or services. Services rendered by
hospitals & members of medical profession for consideration constitutes as defined in the
Act. Deficiency in medical services gives the patient as a consumer the right to claim
compensation, (Poonam Verma vs Ashwin Patel (1996) 4SCC332.)
Nursing as a professional and nurses as an individual have long been advocating for the
welfare of their patients. The impact of health care consumer movement has been to
promote increased accountability on the part of all health professionals including nurses.
Today’s nurse practitioners must be aware of nursing standards, legal issues in nursing, legal
limits of nursing and legal liabilities otherwise he/she will be the first person to be penalized
from the legal standpoint.
Special legal concerns in professional Nursing practices:
Service areas of nursing practices are particularly fraught with legal risk.
Crime: Violation of any law governing the practice of any licensed professional may be
prosecuted as a crime even if no actual harm occurs to the patient e.g. giving medication
without physician’s prescription. Torts are a civil wrong committed against a person & may
be either intentional or unintentional. Physical, emotional, economical harm may also result
in tort. Negligence is the failure to act as a reasonably prudent person e.g. any nurse who
does not meet accepted standard of care or who perform duties in careless fashion runs a
risk of being found negligent. Reighton (1975) identifies some of the common acts of
negligence.
Negligence: fall of a patient from bed, failure to communicate charges in client’s condition,
use of defective apparatus; abandonment; infection due to lack of aseptic techniques; loss
or damage to client’s property; burns from hot water bottle, heating pads, enema, douches
& baths; overlooked sponges in operative procedures; error in identification of patient
including babies.
Malpractices: is the negligence on part of a health care professional Malpractice occurs
when a professional fails to act as a reasonably prudent professional under specific
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circumstances that leads to harm or injury to patients. For example at bed time the nurse
fails to put protective side rails on the bed of elderly disoriented patient and patient falls
from the bed sustaining injuries; other examples are the nurse fails to carry out medical
orders, the nurse abandon a patient needing care; nurse fails to make an accurate
assessment of patient and act on assessment
Assault and Battery: Assault is the threat or an attempt to make bodily contact with other
person without consent. Battery is unconsented or unlawful touching of a parson e.g. a
nurse threats a patient who doesn’t eat meal, the patient may assault her in return giving
the patient an injection against his/her will even on a physician’s prescription is battery.
Patients have the right to refuse treatment even if the treatment would be in the best
interest.
Informed Consent: All patients should be given an opportunity to grant informed consent
prior to treatment. Nursing also must obtain consent for nursing measures to be
undertaken. Nurses can witness patient’s signing of informed consent documents but are
not responsible for explaining the proposed treatment nor are they responsible for
evaluating whether the physician has truly explained the significant risk, benefits and
alternative treatment.
Invasion of Privacy: A claim of invasion of privacy also may be brought against a nurse e.g. if
client has a V.D., the nurse should not disclose the information except if directly relates to
care and Rx. A nurse’s unwanted intrusion in private family matters is another example of
invasion of privacy.
False Imprisonment: Making a person stay in a place against his/her wishes is false
imprisonment.
Defamation of Character: Any communication that injures and individual’s reputation and is
disclosed by another person is considered libel (written) or slander (oral). For example if a
nurse tells a client that his physician is incompetent, he/she could be hold liable for slander.
The nurse who writes such a comment could be sued for libel.
Preventing Legal Problems In Nursing Practice: Legal responsibilities in nursing practice are
becoming of greater importance day by day. But many nurses view the law with
apprehension because they fear being named in a malpractice law suit. With increased
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emphasize on client’s rights nurses today must understand their legal obligations and
responsibilities towards clients. Nurses who give competent care based on their education
will seldom need to worry about a malpractice lawsuit. There are a number of effective
strategies that professional nurses can use to limit the possibility of legal action.
Practice In Safe Setting: in order to be truly safe nurse must be committed to safe patient
care. The safest situation is one in which agency employ an appropriate number and quality
of patients; procedures and personal practice that promote quality improvement; keep
equipments in good condition; provide orientation to new employees; supervise all level of
employees.
Communicate With Other Health Professionals: The professional nurse must have open
and clear communication with nurses, physician and other health care professionals. No
matter how good the nursing is if the nurse fails to maintain clinical records, in the eyes of
the law the care did not take place.
Meet The Standard Of Care: The single most important protective strategy for the nurse is
to be a knowledgeable and safe practitioner of nursing and to meet the standard of care
with all patients. Meeting the standard of care involves being technically competent,
keeping up to date with nursing standard of care, boundaries within which nurse practice. If
a nurse does not perform duties within accepted standard of care they may place
themselves in jeopardy of legal action. Indian Nursing Council Act’s give authority to the
council to maintain standard in the field of nursing education and practice of health care
innovations. TNAI is another source of uplifting standard of nursing care. International code
for nurses is subscribed by TNAI.
Promote Positive Inter Personal Relationship: Even in the face of untoward outcomes from
health care providers, it s usually the unhappy patient that sues. Therefore, the best
strategy for the professional nurse is prevention of legal action through positive inter
patient relationships with patient and team members.
Legal issues confronting practicing nurses today are many but the nurse should view the law
not with apprehension but as a helpful adjunct to define nursing practice.
INDIAN NURSING COUNCIL ACT 1947:
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The Indian Nursing Council, which is the statutory body, came into being through Act that
was passed through the Indian Parliament in 1947, which regulates the nursing education
and practice in the country.
The Indian Nursing Council functions through the State Councils who is responsible for
registration of nurses who have successfully completed and attained entry-level
qualification in nursing. (Baccalaureate program in Nursing for 4 years and Diploma in
Nursing and Midwifery for 3 and half years) It is the function of the council to declare that
such qualification is a legally recognized qualification for the purpose of this act.
However the Act does not have any provision for regulating nursing practice in the states. It
also does not have any system of national examination for nurses’ registration to ensure
standards of nursing education and practice. Neither does it offer any guidelines for
continuing education and systematic ongoing competency assessment for continuation of
nursing licensure.
The Nurses working in different states also need to register with the State Nursing Council.
The state nursing council issues permanent or temporary registration to nurses practicing
within areas under its jurisdiction as per its policies.
16.Management of Information
PURPOSE:
To ensure complete and accurate flow of information in the department to all the nurses.
PROCEDURE:
NS holds nursing departmental meeting every month within 5 days of Hospital
Monthly Review meeting.
NS, ANSs, Supervisors, In-charges and shift in-charges attend the meeting.
Minutes of the meeting are recorded and circulated.
Following Departmental Meeting, every unit is expected to have unit meetings for
dissemination of information and plan of actions decided in the departmental
meeting.
This meeting is also a forum for discussing issues of staff and other related issues.
The minutes of the meeting is sent to NS, and ANS via E-mail or hard copy.
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Area ANS are required to conduct a meeting with their in-charges and form agenda
to be discussed in the monthly meeting.
Apart from the above scheduled meetings HOD can call for emergency meetings of
short duration to tackle emergent issues.
General body meeting will be held once in 3 months.
S. No Report Frequency Purpose
1. NQIP Report Monthly to be To ensure all nurses meet that set
submitted to HOD by standards. To encourage good
20th by respective Unit workers.
In-charges To facilitate corrective actions for
those who have problems.
2. Evaluations 6 Months after joining As per mentioned in the section
and then yearly “Evaluations”
3. Incident Reports As and when required This is for information to higher
authorities and for further action to
prevent such incidents.
4. Attendance Record Monthly Submitted by unit in-charge with
hours worked by each staff in their
unit.
5. Monthly Monthly Minutes of the meeting held
Departmental monthly with unit in-charges,
Meeting supervisors, ANS & NS along with
NQIC members.
6. Unit In-charges Monthly Minutes of the unit meeting held
Monthly Report after departmental meeting for
dissemination of information and
discussion for quality improvement
activities.
7 Unit In-Service Minimum once in a Attendance record submitted by
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Attendance Record month unit in-charges for in-service
conducted in the unit.
8 Unit Statistics Monthly Submitted by unit in-charges in the
approved format at the end of every
month.
9. Daily Report Daily Submitted by shift supervisor for
the purpose of census.
10 Daily Nursing report Daily Submitted by Unit In-charges to
report daily activities
11 ER statistics Daily ER census
12 Incident reports Monthly To collect data of any untoward
incidents
13 Infection Control Monthly To ensure compliance to infection
Statistics control measures.
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16. List of Forms filled by Nurses in Medical records of the patient
1. Nursing Admission Assessment Form with Plan of care: Specific to Adult,

Maternity, Pediatric, Neonate and Emergency room
2. Valuables Handover Form
3. Daily Nursing Flow Sheet : Intake Output Chart, Risk assessment Scores, Care
Summary, Nurses Notes and Plan of care
4. Vital Signs Chart
5. Glucose monitoring Sheet
6. Physician Order Chart for Drug administration Record only
7. Patient and Family Education Record
8. Investigations Chart
9. Radiology Requisition slip
10. Laboratory Requisition Form
11. Endorsement Sheet
12. Pre-Operative Checklist
13. Surgical Safety Checklist (Specific Fields)
14. Recovery Room Chart
15. Blood Transfusion Record
16. ICU Vital Signs Flow Sheet
17. Restraint Form: Care and Assessment only
18. IABP Chart ( as applicable in ICU)
19. Transfer Out Summary (Specific Fields)
20. Transfer Out Checklist
21. Intra partum monitoring (For Labor room)
17. Patient absconding from hospital

PURPOSE
To ensure that all patients admitted under our care are safely discharged from the hospital
after improvement in health.
POLICY
Every patient admitted under our care is discharged from the hospital on his recovery
PROCEDURE
Nurses will meet all their patients whenever a shift is changed
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If a patient is not found in his room/Bed/Toilet, (unless otherwise taken for
investigation/Procedure/ Physiotherapy etc.) the assigned nurse will raise an alarm
and inform the Nursing Supervisor/Charge Nurse/Security Supervisor/IPD/MS. The
IPD personnel will call for the patient’s relative through PA system in the waiting
lobby
If there is no one available, the search for the patient and his relative will begin in
the hospital
If not traceable within the Hospital premises, the nurse will call at their home
address and inform them about the missing patient
Once confirmed that the patient is not traceable, the nurse will inform Security
Supervisor who will inform the police
If no information from patient from security, as per instruction of MS the nurse will
start system discharge process of patient and close the nurses notes
EQUIPMENT
Telephones.
Nurse’s notes.
DOCUMENTATION
The nurse will record all events accurately and completely in her nurse’s notes and will close
the notes once it is confirmed that the police is informed by the security
PREVENTIVE MEASURES:
All patients must be in prescribed uniform with ID band till the time of discharge
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SOP NSG/ADM/1.0
Version : 1.0 Prepared by: CNO, Nurse Educator ,DCNO
Effective from: 01/April/2016 Reviewed by : Roselind Mathews (Regional Nursing Head)
Review date: 31/March/2017 Approved by: Michael Moorhead (National Nursing Head)

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NURSING

Nursing Department: Administrative SOP

3. Fortis Nursing Values

2 Ots 2 nurses per OT in M and E shift, 3 nurses in the night

4 ICUs/Emergency/BMT/Transplant Ratio 1:1.25 -2

7 OPDs 2 nurses per shift for POD of 25

12 Infection Control Nurse 1 per hundred nurses

13 Nurse In Charges 1 per nurse station (No Reliever)

14 Supervisor I per 100 beds per shift or one per shift

ANS/Supervisor ANS/Supervisor ANS/Supervisor

KEY RESPONSIBILITIES: Chief Nursing Officer

Principal Duties and responsibilities:

KEY RESPONSIBILITIES: NURSING SHIFT SUPERVISOR

KEY RESPONSIBILITIES: CHARGE NURSE

KEY RESPONSIBILITIES: NURSE EDUCATOR

KEY RESPONSIBILITIES: QUALITY NURSE

KEY RESPONSIBILITIES: GENERAL NURSE

KEY RESPONSIBILITIES: CARDIAC OT NURSE

8. Performance Standards (for new joiners)

9. Monthly Performance Assessment (NQIP)

The scoring is to be done as given below:

Orientation Training for Change of Responsibility

Training Need Analysis

VAP: Ventilator Associated Pneumonia

14.Nursing Patient Safety Goals

16. List of Forms filled by Nurses in Medical records of the patient

1. Nursing Admission Assessment Form with Plan of care: Specific to Adult,

17. Patient absconding from hospital

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