C 0 N T E,N T S Definitionooooooo.000...00.0.00.uoomoocoooooooooooI...0.00.0000...one.cocoooonuaucnoooo'ooooone... 2 Introd‘mtionooo‘oooooooo00.......000ocoo-Io...00.00.000.000...0-0....ohnooooooooooo-ooooooooool-oo 3 I. General Information: Health Program and Ambulatory Care Nursing..................... Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 II. ACN Resource Table II. Table II. Table II. Table II. 1 2 3 3 U1 General Information..................................................... Population of Service Area.............................................. Population by Age Groups (See Sheet).................................... Others Working in-the Health Care Program............................... Administrative Task Inventory...........................................1 N‘OQQN Availébility..oooooooooo00'...oon.C00f.o0.0000.oto...toot-ooooooo-OIOIOODOIS ACN staff Profile-coo.coco-o1.cocooooooooo-o-oooooooo'ouloo..ooooooo000.017 EquipmentoooooosOcoooooooiosIo.00000.0....oO0..Ito.boooouhooocoooooooooolg supplies.0.00.0.0...o...-I...loo-oooooono..QIQQIQOOOIOIQIo-Ioo0.0.00.00022 References-.0...0’.OIII0“.OO0‘.OIOI.O.-I'7‘O.IIIOOO0..I...I...OO..IOOOIOOC326 III. ACN Functions.0IOIIOOOOOOOOIOOCCOOIIOTOOOOIOOOOOOOOOOIOCOOCIIOOOOOOIDOICOOOOOOOOOIIII3O Function 1. Plan the Ambulatory Care Nursing Program................................33 Function 2. Develop and Refine ACN Program Standards................................36 Function 3. Operate the Ambulatory Care Nursing Program and Services................43 'Function 4. Monitor Ambulatory Care Nursing Program Performance.....................64 Function 5. Evaluate Ambulatory Care Nursing Program................................67. 6. Function 'Appendix I Appendix II Manage Ambulatory Care Nursing Program Resources........................70 ANA standards for “urging serV1ceOOO0.0...I...0.......I-OOIIOOIIOOOOOOOO73 IHS Standards for Ambulatory Care Nursing Service.......................74 ”S04 -5861 I©Sh0 y /fi 5 IOAMy DEFINITION OF AMBULATORY CARE NURSING Ambulatory Care nursing (ACE) practice is the provision of direct and indirect nursing service. It is goal directed to meet the needs of individuals, families, and the community during times of health and illness. Ambulatory care nursing provides comprehensive health care and education to the individual and family in the ambulatory setting. This is accomplished by utilizing the nursing process and coordinating it with the medical plan of care. Continuity of care is accomplished through coordination of services with inpatient and community health programs and utilization of community resources in the prevention of illness and the maintenance of health. Within the Indian Health Service, the ambulatory care nursing staff serve pe0p1e of all ages. ambulatory care nurses apply their skills in and knowledge of clinical nursing, administration, public health, epidemiology, counseling, and education to provide therapeutic, emergency, health promotion, disease prevention and advocacy services. INTRODUCTION PURPOSE OF THE ACN APPRAISAL GUIDE 1. 2. 5. This guide will reinforce understanding of the purposes of Ambulatory Care nursing and the relationships of purposes to functions, functions to resources, and resources to purposes. This guide will reinforce understanding of ‘he evaluation function and will help to implement this function and to use the results in planning and developing ACN programs. The use of this guide will produce a description of the present status of available resources, resource utilization, resource evaluation, resource deficiencies, requirements for additional resources, and priorities for program changes. The guide's design will enable the Area Nursing consultants and Headquarters Nursing Services Branch to abstract data for preparation of a composite description of ambulatory care nursing for each area and IRS. This guide will facilitate orientation, continuity of services and conversion of an ACN program from 135 to a tribal program. OBJECTIVES OF THE ACN APPRAISAL GUIDE 1. 2. Promote systematic evaluation as an integral function of management and operation of the ACN program within the context of a total health program. Define IHS criteria for evaluating: a. Availability of ACN services b. Functions c. Outcomes d. Costs e. Utilization of resources INTRODUCTION (continued) Outline a method for conducting an evaluation of ACN services and utilizing the results. Provide a tool for collecting ACN and health program data, assessing the data, and recording the findings. Provide a task list for the continued development and refinement of evaluation methods and criteria. PURPOSES FOR CONDUCTING EVALUATIONS 0F AMBULATORY CARE NURSING SERVICES 1. 2‘ Determine the effectiveness and efficiency of the ACN program in attaining its objectives. Gain knowledge about the effectiveness and/or efficiency of alternative methods of operating and/or managing the ACN program. Illustrate the needs of the ACN program in relation to the present or prOposed expenditure of resources. Determine compliance with ANA, PBS and IRS Standards for Nursing Service. Assist in preparation for accreditation such as JCAH, Medicaid or state certification as an indicator of the quality of the ACN program. , PART Goal: I. GENERAL INFORMATION: HEALTH PROGRAM and AMBULATORY CARE To provide general information about the ambulatory care nursing services, the clinic facility, the ambulatory and the total health program, the service population, and the community. A. Purpose To assemble a profile of workload and activities. 3. Objectives 1. To provide a tool that can be used to collect basic information about the ambulatory care nursing service, the clinic facility, the ambulatory and the total health program, the service population and the community. 2. To provide a tool for collecting information required for subsequent parts of the manual. C. Methodology The Director of Ambulatory Care Nursing (DACN)/Director of Nursing (DON) or ACN should enter the required Information on TABLES 1.1 - 1.5. 1.1 Table General Information a. Name and location of each facility operated or served by the Service Unit health program; list base facility first. Separately staffed specialty clinics are to be listed individually under base facility. b. Numerical code for type of facility. 1. Hospital beds 6. Boarding School - School Health Clinic 2. Hospital Outpatient Clinic 7. Contract Hospital 3. Health Center Outpatient Clinic 8. Contract MD Office/Clinic 4. Health Station 9. School 5. Field Clinic 10. Other PART I. GENERAL INFORMATION (continued) c- d. e. 8. Number of hours of operation per week. Travel distance in miles and time to satellite facility from base facility. Calendar year (CY) population of service area by facility. Base facility population may include satellite population. Annual patient visits. (1) The number for total outpatients per facility is obtained from the September I-A Ambulatory Patient Care (APC) Report. (2) The number of after hour visits can be obtained from the On-Request APC Report 9 or by local computation. (3) Average daily patient visits per facility is obtained by dividing number of OPV's minus after»hour visits by days of scheduled clinic services. (4) The total number of Emergency Room visits is obtained from the Emergency Room Log. (5) The total ACN visits is obtained from the 1A report by adding the clinic RN (01), LPN (05), Nurse Assistant (22) and any other nursing staff excluding those in column 6. (6) The total NP visits is obtained from the 1 A report by adding the pediatric nurse practitioner, nurse practitioner, and nurse midwife visits. Number of staff by category per clinic. PART I: GENERAL INFORMATION ABOUT AMBULATORY CARE NURSING SERVICE TABLE 1.1 GENERAL INFORMATION (see page 5) e Distance Annual Patient Visits Fro: Base Popula- Name and Facility tion of ver- Location gf or Office Service After age F iii Area tient Hours Dail E.R. ACN / Nurse Primary Care Provider / Non-Nurse Primary Care Provider 1 2 2. TABLE I.2 POPULATION OF SERVICE AREA Indicate population for each tribe as Well as non-Indian. POP 3. TABLE 1.3 POPULATION BY AGE GROUPS OF SERVICE AREA NON-RESERVATION POPULATION URBAN RURAL NON-INDIAN TOTAL SERVICE AREA POPULATION Enter population profile Tor the Service Area by age group and sex. _ I :ACE snows MALE FEMALE TOTAL 0F28 Days f_29 Uaye - 364 Days I”; Yean - 4 Years ._§ Years -19 Year - ) 20 Years - 44 years 45.Years - 64 Years 65 Years — and UP 4. 1.4. OTHERS WORKING IN THE HEALTH CARE PROGRAM! Enter the number of individuals working in the Health Care Program, not included in Table I.1. Part g. Enter average number of hours per week worked in ambulatory care facility. Alcoholism Workers Audiologist Biomedical Engineer/Tech CETA Worker Child Protective Services CHM/PA GEN/PEN CHRs Community Development Dental Assistant Dental Hygienist Dentist Dietician Disease Control Worker, Driver/Interpreter IHS Tribal Other Average Number of Hours Per Week in Ambulatory Care Facility 1.4 OTHERS WORKING IN THE HEALTH CARE PROGRAM (continued) Elderly Aides EMT Environmental Health Worker Engineer Eye Care Aides Family Planning Aides Health Educator Home Health Aides Lab. Technologist/Tech. Law/Order Technician LPN (not clinical) MCH Aides Medical Record Sec/Clerk Mental Health Nurse Midwife Nurse Practitioner Nurse Assistant IHS Tribal Other Average thber of Hours Per Week in Ambulatory Care Facility 10 1.4. OTHERS WORKING IN THE HEALTH CARE PROGRAM (continued) IHS Nutritionist Ophthalmologist Otitis Media worker Physical Therapist Physician Podiatrist Registered Nurse Sanitarian Sanitarian Aide Social Service Student Nurse TBc Control VD Control Tribal Other Volunteers W10 Other Average Number of Hours Per Week in Ambulatory Care Facility 5. TABLE 1.5 ADMINISTRATIVE TASK INVENTORY Identify the person(s) performing the tasks by marking D - Director ACN DON - Director of Nursing/overall Supervisor ADON- Assistant Director of Nursing S NP L Plan for ACN Program Prepare ACN Budget Determine and administer the budget Make recommendations on budget Determine physical layout of work area, furniture, equipment Plan for overtime/leave Establish criteria/guidelines for positions for support personnel Compose/draft agenda for staff meetings Evaluate/select audiovisual material Advise/give assistance in nursing care planning/directing Prepare standards for ACN service Initiate new or changed technical procedures Develop improved work methods and procedures Conduct/plan in—service education programs the blanks as follows: - Staff ACN NE - Nurse Educator - Nurse Practitioner C - Clerk - LPN NA - Not applicable to the Service Unit Develop/establish standards to evaluate manpower performance Prepare standard operating procedures, guides and instructions for use by personnel Consult with staff to design/amend/update procedures/techniques Research material for projegts Write user instructions for new equipment \\ or new procedures Evaluate nursing care procedures and standards Participate in health program committees Recruit ACN personnel Interview ACN personnel Document new or changed procedures Administer/maintain ACN reference library Approve requisitions Train other employees 12 TABLE 1.5 ADMINISTRATIVE TASK INVENTORY (continued) Ensure that personnel are aware of health services available Request/recommend personnel Promote development of teamwork and communications Plan record keeping system for the ambulatory care service Serve as consultant/guest lecturer Arrange transportation for patients/ personnel Monitor utilization of services by patients. Participate in contract negotiations Determine if legal documents for students] volunteers are appropriate and in place Provide technical/administrative supervision Coordinate with hospital/support services Coordinate with other health agencies Conduct staff meetings to discuss plans/activities/problems Review nurse licensure annually Recommend the hiring/termination/reassignment] promotion of personnel Conduct tours of facility for visitors Participate in community affairs Supervise the maintenance of pertinent ambulatory care records Function as Project Officer as assigned Inpatient supervision Implement quality assurance program Contact other facilities to obtain/ coordinate patient care Notify health authorities of patient with communicable disease Audit ACN patient records and care Monitor patient care services Review reports/requests for proper preparation and completion Read/review professional literature 13 TABLE 1-5 Administrative Task Inventory (continued) Investigate/report on injuries] incidents to patient/staff/visitors Participate in research studies/projects Attend professional meetings Acquire, maintain, and audit supplies] equipment for clinic Obtain clarification of conflicting doctor's orders Identify and resolve health care problems Determine manpower and other resource requirements Arrange for replacement/repair of equipment as required Assign space for equipment and supplies Recommend change in manpower levels Compose or revise position/billet descriptions Authorize annual/sick leave Evaluate ACN program Interview/counselladvise staff Determine duties/assignments for personnel’ Make recommendation on approval/disapproval personnel requests to attend meetings] conferences/education/training Coordinate staffing arrangements Counsel personnel on career plans Approve/authorize overtime 14 PART II. ACN RESOURCE AVAILABILITY Goal: To provide information regarding the available human and material resources. A. Purpose: To ensure the Ambulatory Care Nursing Services have resources available to effectively and efficiently provide patient care. B. Objectives: 1. To provide a tool for collecting information about the available resources. 2. To provide a tool for planning and management of ACN program. 3. To provide the DON/DACN/ACN with a single tool for reviewing the quantity and quality of manpower, equipment, and facility resources available. 4. To enable the Area and IRS Nursing Services Branch to abstract and consolidate the above outputs to produce Area and IRS profiles. C. Methodology: 1. The DON/DACN/ACN will collect the required Ambulatory Nursing Service data and make required calculations. 2. The DON/DACN/ACN will enter appropriate information on Tables II-l, II-2 and, 11-3. 3. The health program and area administration will use the data for planning program direction. D. Outcome: 1. The ACN service will be qualified to perform the duties required to accomplish the objectives. 2. The ACN service will have sufficient staff to accomplish objectives. 3. There will be sufficient fixed and other equipment and supplies available to accomplish the objectives. 4. There will be sufficient space appropriately located for ACN service to perform the functions required to accomplish the objectives. 15 INSTRUCTIONS FOR TABLE II.1. ACN STAFF PROFILE Source Documents: Position/billet descriptions Personnel files _ Education and Experience Form (Form HRSA 154-2) Licensure review. Identify Indian Staff by placing * before appropriate position. Individual information refers to person on duty at the time of the review. Positions other than full—time placement such as WAE, permanent, intermittent, volunteer and student staff should be listed separately on second page of the table. ' a. ACN staff-indicate by position code number which positions are authorized. Use blank spaces - if needed; fill in position titles. b. Months vacant during the previOus year - enter only for authorized positions. c. Where appropriate, indicate only one state where currently licensed and date of expiration. d. Academic preparation - enter basic nursing as well as highest degree. e. Enter # of years employed in IHS. f. Enter # of years at the health program. g. 'Enter # of years in present position. h. Enter any additional training of skills such as language, typing, etc. 1. Enter total hours for sick leave for last calendar year. ; 3. Enter total hours for annual leave for last calendar year. k. Enter total hours for training received for last calendar year. 167 TABLE II.1 ACN STAFF PROFILE a b c d e f Lh ACTIVITYTIME €393 g a a z gw of: z HHZZEVJ u ACNSTAFF 0 <0 and; H <§HS vi 3 COMMENTS 5: >z uafi m m- Haw gfiu 2:3 :aaHsogmgmgzé’a a >H ooog E-H-l 2 a: a: GE HE :5 a 9.02:: (nu-14:94 wr—awmwmo mg .4 [-o Director, Ambulatory Care Nursing Supervisor/Head Nurse RN Staff Staff Staff Staff Staff EEQEE Staff LPN Staff LPN Staff Clerical Clerical Nurse Assistant Nurse Practitioner Nurse Midwife Other Other TABLE II.1 ACN STAFF PROFILE (continued) COMMENTS g quzH¢ma m>dma AMMw H< mm .moz a .ENAZDZ mnoo ZOHHHmom ACN STAFF 18 TABLE II. 2 EQUIPMENT INVENTORY Check if available. Add to list as appropriate. Furniture/Room Small Instruments Addressograpb* Biopsy punch* Blackboard Blakemore tube Bookcase* Currettes, ear* Bulletin board* ENT mirrors* Cannister* Forceps, biopsy* Chairs* Forceps, Kelly Chart holder* Curtain, privacy* Desk/writing surface* File, cabinet* File, desk* File, tickler* Fire extinguisher* Hamper , laundry* Medicine box, locked* Peg board Pencil sharpener* Rack, pamphlet literature* Refrigerator* Soap dispenser* Supply cart* Towel dispenser* Typewriter* "all clock* Waste container/lid* *Basic to Open a clinic Forceps, Magill* Forceps, mosquito* Forceps, ring* Forceps, thumb, teeth*_ Forceps, thumb, v/o teeth* Forceps, turbinate* Forceps, uterine* IUD hook* Meele holders* Probes* Retractor Rectal biopsy snares Ring cutter* Scapels* Scissors, bandage* Scissors, curved* Scissors, iris* Scissors, straight* Speculums* ear nasal vaginal Tenaculum* Toenail clippers* Tonsillar suction Towel clips* Uterine aound* Hire cutters* 19 TABLE II 2 EQUIPMENT INVENTORY (continued) Medical Eguipment Medical Equipment Anascope* ‘ Magnifying apparatus* Apron, plastic* Mayo stand* Audioneter* Microscope* Basin* 0pthalmoscope* Bedpan* 0toscope* Blood pressure app.* Oxygen f10wmeter* cuff, large adult ProctoscOpe* cuff, adult cuff, peds cuff, infant cuff, thigh Bucket* Camera* Cast cart* Cast.cutter* Cast scissors* Centrifuge, test tube* Centrifuge, crit tubes* Container, hazardous waste* ~Diaphragn fitting set* Dictaphone* Doppler fetascope* Ear syringe/water pik* Exam-table* Flashlight* Hyfercator IV Regulator, electronic Lamp, gooseneck* Lamp, hi-intensity' HH Procto table Scale, adult* Scale, child* Scissors, trauma Sigmoidoscope Spirometer Sterilizer* Stethoscope* Stool, wheeled* Stretcher* Thermometer, electric* Tonometer* Tonometer sterilizer* Tube gauze applicator* Tube syrigne holder* Tynpanoneter* View box* Vision tester* Wheelchair* Woods lamp 20 TABLE II. 2 EQUIPMENT INVENTORY (continued) E.R. Equipment Pack/Tray Set Air splints* Bone marrow Ambu bag* Burn pack infant Central line (sub—clavian) pediatric Chest tube adult Circumcision Cardiac board* Cutdown Crash cart* V D and C Defibrillator* ENT Drug box, transport* Eye Electrocardiograph* Gastric lavage I.V. poles/track* I and D* Larygnoscope, curved/straight* IUD* adult Lab* infant Minor surgery* pediatric 0.B.* Light, surgical* Suture* Mast trousers* Toenail removal Oxygen supply (including portable)* Tracheotomy Papoose board* Restraints* Sand bags* Suction machine* *Basic ER equipment 21 TABLE II.3 SUPPLIES INVENTORY Check on line provided if available. Enter actual numbers where appropriate. Note deficiencies, reasons, and other pertinent information in comments column. Add to list as necessary. Medical S ‘lies ¥ Ace bandage Adaptic Adhesive tape (assorted sizes) Hicropore (assorted sizes) Cotton fabric backing an—uoven (Hicropore) assorted sizes Airway infant child medium adult" large adult Alcohol prep pad Applicator, cotton-tipped Arm board child adult Autoclave cleaner Autoclave controls (kilit) Autoclave tape Bag, urine collecting, pediatric Bandage, adhesive Band-aid Bandage, cast, plaster of paris Bandage, elastic Bandage, felt, orthopedic Bandage, gauze 2' wide 3' wide 6' wide 6' wide Bandage, gauze, tubular Bandage, (Kerlix) Bandage, muslin Basin, emesis Batteries - AA, C, D Belt, rib Betadine prep pad Medical Supplies Blade, surgical knife # 10 # 11 i 12 Breast pumps Brush and sponge, surgical scrub Bulbs Calgiswab Cane, walking Cannula, nasal oxygen Cape, exam or x-ray Catheter, chest Catheter intravenous placement unit (Angiocath Jelco) jugular starter set suction (tracheal) 5/6 French 8 French 10 French lb French 18 French urethral Foley straight Catherization kit (female) Catherization tray, urethral Cervical collar Cervical scraper Chart paper, audiogram Chest tube, drainage (pleuro-vac) Chlorhexidine gluconate skin cleaner (Bibiclens) clavicle strap Cold pak Collar, cervical Comb, nit Connector, straight Cotton balls . Cover, Ivac 22 TABLE _II.3 SUPPLIES INVENTORY (continued) Medical Supplies (Continued) Crutch Crutch accessories axillary cushion hand grip cushion tip Culture collection & transport system 00? medicine water urine spec. Depressor, tongue non-sterile sterile Detergent 8 disinfectant concentrate Diaper, infant's, disposable Drape sheet surgical, sterile fenestrated non-fenestrated Electrocardiograph paper Electrocardiograph Paste Electrodes for cardiac monitor Enema sets Endotrachial tubes, assorted sizes Envelope, sterilization Eye pad ' Fiberglass casting materials stockinet tape, assorted sizes Finger guards Gauze, absorbent iodoform plain Gloves noanterile sterile Medical Supplies (Continued) Gown, exam or X-ray Reel, orthopedic cast Identi-Bands (patient name band) Injection caps, (Heparin lock) Intrauterine device Intravenous administration Set blood admin. tubing extension tubing microdrip regular drip Otoscope Lubricant jelly (KPY jelly) Lumbar puncture tray infant pediatric adult flask, oxygen adult size single concentration variable concentration (Venturi Style) child size Mask, Surgical Mini-nebulizer (hand-held) Rasogastric tube Needle, hypodermic 18 G x 1—1/2“ 20 G 1' 1—1/2” 21 G x 1—1/2“ 22 G x 1' 23 G x 3/4“ 25 G x 5/8" 27 G x 1-1/b' Needle, spinal puncture 18 G x 3-1/2“ 23 TABLE II.3 SUPPLIES INVENTORY (continued) Medical Supplies (Continued) 20 G x 3-1/2" 22.6. 2-1/2” 3-1/2" Obstetrical pack Pad, abdominal Pad, bed linen protective (Chux) Pad, eye Pad, non-adherent (telfa pad) Pad, sanitary, Pap kit (PAP pak) Paper sheeting, exam/treatment tables Penrose drains Pillowcase Pin, safety Plastibell, assorted sizes Rape evidence collection kit Razor, surgical preparation _Sanitary belt Scissors, bandage Silicone aerosol Sling, arm, cradle Specimen cup Specula Vaginal, for use with illuminator Splint, clavicular, universal siz Splint, finger_(aluminum) ' Splint, baseball Splint, wrist & forearm (aluminum with foam) left arm small medium large right arm small medium large Medical Supplies (Continued) Sponge, surgical non-sterile 2" x 2" 4“ x 4" sterile 2” x 2" 4' x A" Steri-grip Stockinet (assorted sizes) Stopcock Stylet adult pediatric Suture, surgical 3/0 ‘Chromic gut (absorbable) \ Silk, black braided FS-l needle X l needle 4/0 Chromic gut (absorbable) Nylon (Ethiolon), black monofilament Polyester (Ethibond), green braided FS—l needle _ ‘ FS-Z needle Polyglycolic acid (asorbable) Silk, black braided, cuticular 18“ length 5/0 ". Polyester (Ethibond), green braided 24 TABLE II.3 SUPPLIES INVENTORY (continued) Medical Supplies (Continued) ‘ .¥olyglycolic acid (asorbable) Silk, black braided, FS-Z needle 6/0 Nylon (Ethilon, cuticular, 18" Black monofilanent clear monofilament Polypropylene (Prolene), blue Monofilament, P-l needle Suture removal kit Swab, large (Phoenix) Syringe, ear/ulcer 2 oz 3 oz Syringe, hypodermic, Lust-lock tip 5-6 ml 10-12 ml 20 ml 50 - 60 m1 Syringe and needle general purpose type, 2-1/2 - 3 m1 Insulin type, for use with U-lOO- 0.5 ml (50 units capacity) 1 ml (100 units capacity) Tuberculin type, 25 G x 5/8" needle Syringe, tube for both 1 & 2 ml cartridge | Medical Supplies (Continued) Tape measure, infant/pediatric Tape, sealing Thermometer oral rectal Tissues, facial, 2-ply patient bedside size, 5' x 8“ regular size, 9.2" x 8.5" Tourniquet Towel, wiping paper Towelette,’cleaning Tracheotomy tubes Tube, connecting, flexible, plastic general purpose, for fluid 5 gas oxygen,.for lengthy connecting Tube, stomach, (nasogastric) 16 French 18 French Unna Boot Urinal, male patient Urinary drainage bags Vaseline gauze "adding, cotton, surgical, rolled Washcloth, non-woven material Wrapper, sterilization Crepe paper, Kraft 20" x 20" 25 "mm 11.4 mucus Check if available. Add to 1tst as appropriate JOURNALS: Journal of Energency Nursing 666 north Lake Shore Drive, Suite 1131 Chicago, Illinois 60611 The Journal of Ambulatory Care Management Aspen Publicatioh 1600 Research Boulevard Rockyille, Maryland 20850 Critical Care nurse 680 Route 206 North Bridgewater, NEW Jersey 08807 Critical Care Update P.0. Box 5828 Orange, California 92667 26 10. 11. 12. 13. TABLE II.4 REFERENCES (continued) BOOKS: Rund, Douglas A. and Rausch, Tondra S., TRIAGE. St. Louis: The C.V. Mosby Company, 1981. PEDIATRIC TRIAGE MANUAL. Fort Sam Houston, Texas: Brooke Army Medical Center, 1979. ADULT TRIAGE MANUAL. Fort Sam Houston, Texas: Brooke Army Medical Center, 1979. Budassi, Susan A. and Barber, Janet M., EMERGENCY NURSING. St. Louis: The C.V. Mosby Company, 1981. Budassi, Susan A. and Barber, Janet M., MOSBYFS MANUAL OF EMERGENCY CARE. St. Louis: The C.V. Mosby Company, 1979. ANA, STANDARDS OF EMERGENCY NURSING PRACTICE. Kansas City: ANA, 1975. Aguilera, Donna C. & Messick, Janice M., CRISIS INTERVENTION, Theory and Methodology. 4th edition, St. Louis: The C.V. Mosby Company, 1978. Gibbs, Ronald S. and Gibbs, C.E., AMBULATORY OBSTETRICS. New York: John Wiley and Sons, 1979. ' Wilson, Laura 3., Simson, Sharon P. and Baxter, Charles R., HANDBOOK OF GERIATRIC EMERGENCY CARE. Baltimore: University Park Press, 1984. NURSING CARE or INFANTS & CHILDREN. Haley and Wong, 2nd edition, St. Louis: The C.V. Hosby, 1982. Gahart, Betty L., INTRAVENOUS MEDICATIONS. 3rd edition, St. Louis: The C. V. Mosby Company, 1981. Govoni, Laura E.& Hayes, Janice E., DRUGS and NURSING IMPLICATIONS. 4th edition, Norwalk, CT: Appleton—Century—Crofts, 1982. Corbett, Jane V., LABORATORY TEST in NURSING PRACTICE or Reference for Clinical Laboratory Tests. Norwalk, CT: Appleton-Century-Crofts, 1982. , 27 TABLE 11.4 REFERENCES (continued) 10. 11. 12. 13. 14. 15. 16. 17. 18. BOOKS THAI SHOULD BE AVAILABLE IN AN AMBULATORY NURSING SETTING: (BZ Togic Onlz) MEREK MANUAL DICTIONARY, MEDICAL DICTIONARY, WEBSTERS LIPPENCOTT MANUAL OF NURSING PRACTICE (PDR) PHYSICIANS DESK REFERENCE NURSING DRUG HANDBOOK NURSING PROCESS TEXT NURSING DIAGNOSIS TEXT LABORATORY VALUE INTERPRETATIONS, etc. PHYSICAL ASSESSMENT BOOK CONTROL OF COMMUNICABLE DISEASE * 'REDBOOK" "Tncn TOXICOLOGY REFERENCES/POISON CONTROL INFO. HANDBOOK of GERIATRIC EMERGENCY CARE PEDIATRIC & ADULT TRIAGE MANUALS TRAUMA REFERENCE EMERGENCY ROOM CARE - (Mosby's Manual of ER Care) CRISIS INTERVENTION (Mosby) CRITICAL CARE NURSING 28 TABLE 11.4 REFERENCES (continued) 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. BOOKS THAT SHOULD BE AVAILABLE IN AN AMBULATORY NURSING SETTING: (By Togic Only) EMERGENCY NURSING AMBULATORY OBSTETRICS PEDIATRIC NURSING OBSTETRICAL NURSING PATIENT FAMILY EDUCATION INFECTION CONTROL CHEMOTHERAPY, Ambulatory Nursing PATIENT CARE STANDARDS CHEMOTHERAPY, Practices and Procedures and Ambulatory Nursing Care. DISASTER NURSING REGIONAL ANESTHETICS CRITICAL CARE NURSING TEXT LEGAL ASPECTS OF NURSING NURSING MANAGEMENT/LEADERSHIP QUALITY ASSURANCE - AMBULATORY IHS NURSING APPRAISAL TOOL/AMBULATORY IHS NURSING CRITERIA 0F CARE/AMBULATORY HEALTH PEOPLE POLICY & PROCEDURE MANUALS, IHS & Facility 29 Part III. AMBULATORY CARE NURSING FUNCTIONS A. Goal: To provide the criteria for compliance with the ANA Standards for Nursing Service and the IHS Standards for Ambulatory Care Nursing Services. (See Appendix I and II.) Purposes of Part III of the Appraisal Guide: l. 2. 3. 4. To reinforce the Ambulatory Care Nurse's (ACN) understanding of the rationale supporting the functions of the ACN in the health program. To provide a common frame of reference for communication about ACN activities among the health programs, Area, and Nursing Services Branch. To enable DON/DACN/ACN's to develop programs to comply with the applicable evaluation criteria in accord with the requirements of their respective health programs and the availability of resources. To provide a baseline description of ACN activities for each ACN program that can be consolidated into Area and IRS profiles. Objectives of Part III of the Appraisal Guide: lo 2. 3. To provide DON/DACN/ACN'S with a tool for reviewinggthe activities of the ACN service for quality in relationship to ANS purpose and role infthe health program. To provide a tool for collecting information for uSe in the planning and management of the ACN program. To provide an evaluative tool for the health program, Area, and Headquarters Nursing Services Branch for use in planning, standard setting, operating, monitoring, and management of ambulatory nursing services. 30 c- D. Part III. AMBULATORY CARE NURSING FUNCTIONS (continued) Methodology of Part III of the Appraisal Guide 1. The DON/DACNIACN should review the program by: b. C. Comparing the program activities with the criteria listed. The criteria describes what should be done to accomplish the purposes of ACN. Checking the appropriate level of compliance with the criteria listed in this tool. Commenting on compliance with the criteria, problems constraining compliance, inappropriate criteria and future actions to be considered. 2. The Area Nursing Consultant will use this tool as part of the annual review. 3. The DON/DACN/ACN Area Nursing Consultant should compare their respective reviews. A plan for the ambulatory program that meets the requirements of the health program and the approval of the Health Director and/or Service Unit Director will be developed. ' 4. The DONYDCN/ACN and Area Nursing consultant will report findings of the review to the staff, health program and Area Administration. Purposes of Ambulatory Care nursing Service Functions 1. 2. To assure that skilled nursing services are available and accessible. To assure that nursing service conforms to standards of quality and quantity as defined by consumers and health professionals. To assure that health services are administered and used appropriately. To assure that nursing services are included in the total health management plans of consumers. To provide primary and secondary health services within the health program. 31 G‘U‘Ib PART III. VAMBULATORY CARE NURSING FUNCTIONS (continued) THE FUNCIIONAL ANALYSIS PROCESS WAS UTILIZED TO DEVELOP THIS PART OF THE GUIDE. The ACN program functions are: 1. Plan the ambulatory care nursing program. 2. Develop and refine ACN program standards. 3. Operate the ACN program and services a. Direct the clinic: 1) Administer Ambulatory Care Nursing Service 2) Coordinate with other disciplines for the continuity of patient care 3) Assume responsibility for procedural control activities directed toward continuity of care b. Provide patient care utilizing the nursing process: 1) Assess patient 2) Plan care 3) Implement care a) Provide therapeutic care b) Educate patients and family c) Provide counseling to patient and family d) Coordinate patient care e) Document care 4) Evaluate care c. Initiate and conduct special studies for improvement of patient care. d. Act as patient advocate in the health delivery system . Monitor ambulatory care nursing program performance . Evaluate ambulatory care nursing program . Manage ambulatory care nursing program resources 32 FUNCTION: 1. PLAN THE AMBULATORY CARE NURSING PROGRAM The Ambulatory Health Nursing Service shall plan the ACN program to provide comprehensive, preventive and therapeutic nursing services, and health promotion activities in accordance with accepted standards of nursing practice. The plan shall promote the effective utilization of available resources. Written documentation of the planning process shall be reflected in the ACN program plan and/or in the minutes. Criteria compliance Yes In Part IVA consents A. Planning shall include participation of members of ACN staff in the assessment, development, implementation, and evaluation of the ACN plan. Planning will include the development and implementation of the philosophy and objectives for the ACN program. Planning shall include establishment of priorities. Planning shall include resources to be utilized. Planning shall establish a mechanism for communicating needs. ACN planning shall define the functions of the ACN staff. ACN staff shall participate in health program planning at the local level. 33 FUNCTION: 1. PLAN THE AMBULATORY CARE NURSING PROGRAM (continued) Criteria Compliance Yes In Part NIB comments H. I. J. K. Planning shall provide a mechanism for coordinating with other health services. Clinical experiences for staff, students, and health aides shall be provided for within the plan. The Director of the Ambulatory Care clinic DACN/ACN staff, with consumer participation, shall plan for patient care programs and for expansion of services which are developed to meet health needs of the community. Planning shall include collaboration with IRS Area Office, nursing services, with the state health department, with the county health department, Native associations and/or tribal unit. Planning shall include orientation activities for staff, tribal employees, official visitors, students, volunteers and other community agency employees. Planning shall include staff education, in-services, and other training experiences. ”um—«raw.- 34 FUNCTION: 1. PLAN THE AMBULATORY CARE NURSING PROGRAM (continued) Compliance Criteria In You Part Ill ecu-ants N. Planning shall include a mechanism for reporting the following: 1) Achievements of established goals. 2) Highlights of the year. 3) Plans for the future. 4) Quality Assurance Activities A written plan for quality assurance will include: 1) Objectives 2) Monitoring 3) Evaluation 4) Problem solving 35 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS The ACN Service shall develop and refine the ACN program standards which can be monitored for compliance and effectiveness. Criteria Compliance Yes In Part Ila Cc-snts A. H. There shall be an organization chart which shows channels of responsibility and authority. The role of ACN service and its relation to total Service Unit/health program shall be defined. The DON/DACN shall have scheduled meetings with the health program Director and/or delegate to discuss and set policy. ACN service shall be available in each Ambulatory Care program/facility within the Indian Community. There will be consumer input in the development of ACN services, policies, standards and program. There shall be a system for coordination of services between disciplines to provide for continuity of patient care. Standards of Performance shall be developed for all levels of ACN staff with employee participation. Standing Orders as required by individual ACN sites shall be signed by the responsible physician(s): * 36 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Compliance Criteria In Yes Part N/A Comments I. Medical protocols shall be developed and signed by the nursing staff involved and a physician currently assigned this responsibility. Guidelines shall be available which relate to at least: 1) Laboratory and X-ray 2) Nutrition 3) MCH 4) School Health Program 5) Health Promotion/Disease Prevention 6) Communicable Diseases 7) ,Immunizations ‘ 8) Specialty Clinics 9) Patient Teaching 10) Emergency Nursing 11) Other Services impacting on nursing Audit criteria shall be developed for three conditions selected by the health program. There shall be documentation of needed patient services which are not available as well as documentation of requests for such services. 37 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Criteria Chapltonco Yes In Part WA eta-cuts There shall be regularly scheduled administrative meetings with ACN staff to discuss ways to improve ACN services. Area Consultant for Ambulatory Nursing Services shall provide on site review and consultation at least once a year. Policies and procedures manuals for ACN program and practices shall be available: 1) Procedures shall be dated with original and revision dates. 2) Manuals shall contain alphabetical index for ready reference. There shall be written policies and procedures reviewed and approved annually which relate to at least: (JCAB criteria) 1) The patient appointment system. 2) The mechanism used to inform a patient of practitioner(s) responsible for his care. 3) The ambulatory care patient medical record, including reference to the confidentiality of patient information and the safeguarding of records, the release of information to authorized individuals, and any required consent for treatment. 38 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Compliance Yes Part “In Commants 4) The scope of treatment allowed in specific elective procedures that may not be performed by medical staff members. 5) The limits of the use of anesthetic agents and the surgical procedures that may he planned in such areas. 6) Persons other than MD's who may perform specified procedures, under what circumstances, and under what degree of supervision. 7) The mechanism for provision of care to unemancipated minors not accompanied by parent or guardian. 8) The location, storage and procurement of medications, supplies, and equipment. 9) The dispensing of medication in accordance with legal requirements. 10) Infection control measures. 11) Safety practices. 12) Required reporting of communicable diseases of appropriate authority. 13) Role of ambulatory care service in hospital internal and external disaster plans. 14) The use of standing orders. 15) The handling and safekeeping of patient's valuables when patient undergoes anesthesia for surgery. 16) Method for recall of patients needing further care as indicated by results of a diagnostic test. 39 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Criteria Compliance Yes In Part "/5 comments Q. There shall be written procedures for ambulatory surgery which include: (JCAH criteria): 1) Types of emergency and elective operative procedures that may be performed. 2) Type of anesthesia which may be used. 3) Preoperative evaluation. 4) Valid operative permit. 5) Physician conference with patient on procedure, anesthesia and potential risks. 6) Written preoperative and postoperative instructions. 7) Review of patients requiring hospitalization after ambulatory surgery. 8) Handling of surgical specimens. VThere shall be a policy and procedure manual written for Emergency Room management including: 1) Scope of treatment allowed, procedures that may be performed and use of anesthesia. 2) Location, storage and procurement of mediations, supplies and equipment. 3) Provision of care to unemancipated minor not accompanied by parent or guardian, or to an unconscious patient. 40 FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Criteria Co-pl isnco Yes In Part MIA Comments 4) 15) 16) Release of authorized information and materials to police, health authorities or personal physician. Transfer and discharge of patients including pertinent documents. Infection control measures. Safety and traffic control practices. Dispensing of medications. Confidentiality and safeguarding of patient's record. Handling and safekeeping of patient's valuables. Role of emergency department in hospital disaster plans, including equipment failure. The use of standing orders. Circumstances that require the patient to return to the E.R. Care of alleged or suspected sexually assaulted victims, child abuse, emotionally disturbed patients, patients under influence of alcohol or drugs, or exposure to radiation; management of pediatric emergencies. The initial management of patients with burns, hand injuries, head injuries, poisoning, animal bites, gunshot and stab wounds. Precautions to be taken in preventing the occurrence of accidents to unconscious or irrational patients. 41 _ FUNCTION: 2 DEVELOP AND REFINE ACN PROGRAM STANDARDS (continued) Coup) lance Criteria In Yes Part "/3 Comments 17) Tetanus, rabies, and plague prevention- prophylaxis. 18) Property exchange system necessitated by patient transfer. 19) Handling of patients dead on arrival. 20) Persons other than MD's who may perform S. specified procedures, under what circumstances, and under what degree of supervision. Policies and procedures shall provide for independent nursing referrals. 42 FUNCTION: 3. OPERATE THE AMBULATORY CARE NURSING PROGRAM AND SERVICES a) Direct the clinic 1) Administer Ambulatory Care Nursing Service: Criteria The management of the ambulatory care nursing service shall be performed to assure that appropriate and required services are organized to provide direct services to the consumer effectively and efficiently. Chlplllnc. Yes In Part No “II Comments c. F. G. The administrator of the ambulatory and emergency nursing services shall be a qualified registered nurse with appropriate education, experience and licensure, and shall have demonstrated ability in ambulatory and emergency nursing practice and administration. The DON/DASH shall have responsibility, account- tability and authority for the direction of the ambulatory nursing service. The objectives and scope of services are defined in writing including criteria used to determine eligibility. DON/DASH shall provide for nursing services in the base and satellite clinics. Qualified nursing supervision shall be provided for each level of ambulatory nursing personnel. Nursing services are provided by sufficient, competent, appropriately educated personnel who are available for the volume and type of ambulatory and emergency services provided, i.e. RN coverage and availability after hours. Nursing personnel assignments shall be consistent with level of education, experience and demonstrated competence to provide safe and effective nursing care. 43 FUNCTION: 3.a.(1) Administer Ambulatory Care Nursing Service: Criteria Compliance Yes In Part "/3 Comments Level II emergency department services shall have at least one RN and sufficient number of other nursing personnel permanently assigned, and on duty within the ER at all times. Level III shall have an RN available at least on an on-call, in-house basis at all times, who has been prepared through appropriate ER training and educational programs. Ambulatory care nursing service shall be provided in accordance with established standards of nursing practice. Written policies and procedures shall be utilized in the administration of ACN service and provision ' of patient care. Current and appropriate protocols/standing orders shall be utilized by nurses and paramedical personnel. There shall be ongoing relevant orientation in—service and continuing education program. The DON/DACN shall participate in orientation and training programs for employee, visitors, students, volunteers, and other community agencies. Ambulatory care nursing shall administer organized patient education programs such as MCH, diabetes, accident prevention. 44 FUNCTION: 3.a.(1) Administer Ambulatory Care Nursing Service (Continued) Compliance Criteria In Yes Part IVA Cements P. The ACN shall provide visual and auditory privacy both in the triage and exam area. There shall be a means of communicating in the language of the predominant population served. There shall be a staff educational program directed towards increasing clients responsibility for their own health care. Other health care resources and specialist consultation shall be utilized in areas such as rehabilitation, nutrition, and mental health. The DON/DACN shall inform the health program director regarding developments, progress or changes in the ACN program. The DON/DACN shall share responsibility with the health program and Area staff for preparing a written agreement with educational institutions for the use of the agency's clinical facilities for students. The management of ACN supplies shall be the joint responsibility of the administrative services and the ACN department. There shall be a system to assure that equipment and supplies are readily available and properly stored. -4 _,,r..._. _ 45 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services a. Direct the Clinic: (2) Coordinate with other disciplines for the continuity of patient care: The ambulatory care nursing service shall coordinate with other disciplines to assure comprehensive care. Criteria Compliance Yes In Part IVA comments A. C. The ambulatory care/emergency room services shall be appropriately integrated with other health program services. The duties and responsibilities of all staff disciplines providing care in the ambulatory care department and their relationship to each other shall be defined in writing. The ACN's routine clinic activities will promote continuity/coordination of care with inpatient nursing, community health nursing and other disciplines. ACN in conjunction with community health nurses shall utilize a tracking system for follow—up of referrals. Evidence shall be available showing that appropriate referrals have been made, feedback is received and follow-up care is implemented. There shall be a system for the transference of program policy changes affecting ambulatory care nursing services and coordination of patient care. 46 FUNCTION: 3.a.(2) Coordinate with Other Disciplines for the Continuity of Patient Care: (continued) Criteria Compliance '03 In Part ll/A Comments G. There shall be ACN participation in organized health program committees such as community health and emergency service to promote communication and improve management of patient care services. H. There shall be cooperation with IHS Area Office Nursing Branch, state, county and tribal health departments. 1. ACN shall participate in the implementation of an overall patient education program. 47 EUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services a. Direct the Clinic (3) Assume responsibility for procedural control activities directed toward continuity of care. DACN shall implement procedural controls to promote quality patient care. (an-plum cumu In Yes Part No "(A Comments A. The record system shall be utilized according to health program policy. { 1) There shall be controlled access to health records, and confidentiality shall be maintained. 2) There shall be a mechanism for release of information to other health care facilities, health authorities, and legal systems. 3) Health care records shall be utilized by other health care providers, i.e. community health services, mental health services, nutritional, chemical dependency services. 4) The'language used in the patient's record shall reflect professional standards. B. A health record shall contain at a minimum: 1) Patient identification. 2) Relevant history of the illness or injury and physical findings. 3) Diagnostic and therapeutic orders. 48 3.a.(3) Assume responsibility for procedural control activities (continued) FUNCTION: Compliance Criteria In Yes Part “In mu 4) Clinical observations, including results of treatment. 5) Reports of procedures, tests and results. 6) Surveillance record. 7) Problem list. 8) Patient disposition and any pertinent instruction given to the patient and/or family for follow-up care. 9) Immunization record. 10) Any allergy history. 11) Growth charts for pediatric patients. 12) Referral information to and from outside agencies including contract authorization forms. 13) Nursing documentation which reflects the nursing process and a plan of care. Nursing documentation in the health record shall reflect health status, a plan of care, and health care provided:‘ 1) 2) 3) 4) Care provided shall be recorded in the subjective, objective, assessment, plan intervention and evaluation (SOAPIE) format. Patient contacts (i.e., telephone calls, clinic visits, emergency room visits) shall be recorded. A master problem list shall be utilized. A surveillance record for health maintenance shall be utilized. 49 FUNCTION: 3.8.(3) Assume responsibility for procedural control activities (continued) Criteria Complianc. You In Part IVA Comments D. 5) The initial nursing assessment performed on all new patients shall be recorded. A tracking system shall be in place for patients with selected conditions from initial contact through follow-up requirements, i.e. reportable communicable disease, chronic illness, pregnancy, well child, selected family planning clients, abnormal test results, selected patients presenting to the emergency room. There is a plan for follow-up for care, including broken appointments. Independent nursing referrals are made according to policy and procedures. The ACN shall follow the written policies and procedures for intake and provision of service, i.e. eligibility, history, patient record available. The system for patient flow and sequence of services shall be utilized. A current list of appropriate professionals, referral and consultation services, and community resources shall be available and used. Patient's consent shall be obtained if trainees participate in care. 50 FUNCTION: 3.a.(3) Assume responsibility for procedural control activities (continued) muons man- In 1.. 3.3; '9 "I. Comments K. Written guidelines shall be available and M. N. O. P. R. utilized for the general upkeep of examining rooms and nursing areas. Orientation shall be provided for all new staff members according to established program. Documented scheduled in-service programs shall include: 1) Emergency care. 2) Safety and infection control. 3) CPR training. There shall be prominently displayed posters on: 1) CPR 2) Burns 3) Poison Telephone number of the regional poison control center shall be posted at the telephone. Currently toxicology reference material and antidote information shall be readily available. A locator file for all major supplies and equipment shall be readily available. A preventive maintenance program exists and shall be utilized for special equipment. '51 FUNCTION: 3.a.(3) Assume responsibility for procedural control activities (continued) Criteria compliance In In Part III Comments s. T- U. w. X. A check list for emergency supply equipment and drugs shall be completed daily according to written policy. Emergency medical technicians or other allied health personnel providing care according to written policy. The role of the emergency room in the internal and external disaster plan shall be defined. The name of each patient who seeks emergency care shall be entered in an ER log, HRSA 457. The log shall contain name, age, sex, date, time, means of arrival, complaint, description, time of departure and disposition of each patient upon discharge. The emergency room form HRSA 114 is used according to IRS policy. Transfer criteria shall be defined and shall contain at least the following: 1) No patient will be transferred arbitrarily if the hospital can provide adequate care. 2) No patient will be transferred before the receiving hospital has been notified and agreed to accept the.patient. 3) No patient will be transferred until sufficiently stabilized. 4) Responsibility for patient during transfer will be established prior to the transfer. 5) All pertinent medical information will accompany the patient. 52 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services b. Provide Patient Care: The nursing process shall be utilized in the delivery of nursing services to all patients. (1) Assess Patient: Assessment provides a data base for analysis of the nature of health condition and severity of illness or injury and the need for intervention. Criteria Chlpltllfl. You In Part III Comments There shall be a systematic collection of pertinent subjective and objective data concerning the health status of the patient. Data shall be collected from the patient, family, significant others, members of the health team and the patient's health record. A nursing diagnosis shall be derived from data collected and shall be stated in accordance with accepted terminology as identified in the IHS Manual, Chapter 4 Nursing. Every patient entering the AC and ER system shall be triaged in a timely manner. A complete nursing assessment shall be done according‘to written policy. Significant data are recorded and communicated to appropriate persons. 53 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services b. Provide patient care utilizing the nursing process (2) Plan Care: ACN shall formulate a comprehensive nursing care plan for the patient and collaborate in the formulation of the overall patient care plan. Criteria Compliance Yes In Part “In Oo-ento The plan shall reflect consideration of environmental, physical and psycho-social factors affecting the health status of the patient. Priorities shall be determined for identified nursing diagnoses that are the most urgent and critical. A nursing care plan shall be formulated for identified nursing diagnoses. The plan shall include goal, nursing interventions, and expected outcomes, and shall be written precisely, concisely and systematically. The patient, family, significant others, and other health team members are involved in planning. Subsequent visits show reassessment of the patient and revision of the care plan to meet changing health status. 54 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services. b. Provide patient care utilizing the nursing process. (3) Implement patient care: ACN shall provide comprehensive preventive, therapeutic, and health promotion activities in accordance with the accepted standards of nursing practice. (a) Provide Therapeutic care: Ambulatory care nursing will carry out nursing interventions and physician orders in accordance with the accepted standards of nursing practices. Coup! tans. Criteria In Yes Part no “/5 Comments A. Ambulatory care nursing staff shall promote safe and therapeutically effective nursing care through implementation of established standards of nursing practice. B. The policy and procedure manual shall be used as a guide in the provision of nursing care. C. The Ambulatory Nursing Service Criteria of Care Manual shall be utilized. D. Standardized care plans and teaching plans are utilized. E. Ambulatory care nursing shall initiate and provide emergency care utilizing standing orders/protocols until a physician or other PCP is available. F. Ambulatory care nursing shall provide safe patient care. G. Ambulatory care nursing shall be responsible to clarify orders for medication and treatment. H. The ambulatory care nurse shall document in the patient record, all physician orders and nursing interventions as they are carried out. I. The nurse shall involve patients and family in the decision—making process. 55 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services b. Provide Patient Care (3) Implement Patient Care (b) Educate Patient and Family: ACN shall promote health practices by meeting the learning needs of patients, families and communities. Compliance Criteria In Yes Part No “/3 Comments A. Learning needs shall be identified and addressed. B. The ACN shall provide health information to the patient and family taking into consideration their intellectual and emotional capabilities and their readiness to learn. C. The nurse shall explain treatments before their initiation. D. The nurse shall explain and/or reinforce information regarding medications, treatments, self-care and referral. E. Written instructions regarding after care, follow-up and/or referral shall be provided and explained when appropriate. F. The nurse shall assist patients and/or family 2 in the identification of factors that place them "at risk" for illness or injury. G. Appropriate health promotion concepts, activities, and methods for disease or illness prevention shall be explained. H. Patients shall be taught signs and symptoms of disease to promote early detection and intervention. 56 FUNCTION: 3.b.(3)(b) Educate Patient and Family: (continued) Criteria Coup) ianco Yes In Part Illa Comments The nurse shall disseminate information concerning access to and utilization of the health care system including contract and emergency care. The nurse shall provide information to patients which enables them to make appr0priate decisions about deciding when to seek medical care. Health education material shall be easily accessible to patients and providers. Health education material should be culturally sensitive. The health record shall reflect teaching by the ACN. 57 FUNCTION: b. Provide Patient Care (3) Implement Patient Care (c) Provide Counseling to Patient and Family: related to counseling to implement nursing care. 3. Operate the Ambulatory Care Nursing Program and Services The ACN shall utilize a body of knowledge Criteria Compliance Yes In Part "In Chm-eats The AER shall utilize therapeutic communication techniques, stress management, crisis intervention and counseling skills to implement the plan of care for specific nursing diagnoses. The ACN shall utilize a variety of data and resources to identify patients with counseling needs in situational crises, i.e. medical diagnoses, ER log, obituary columns. The AER shall evaluate patterns of coping, support positive coping mechanisms and assist the patient to replace inadequate coping mechanisms. The AER shall make follow-up nurse counseling appointments with patients as indicated. The ACN shall independently make referrals for counseling services when indicated, i.e. psychologists, social workers, alcohol and drug counselors, womens' advocates, sexual assault advocates, abortion counselors, etc. 58 FUNCTION: 3. Operate the Ambulatory Care Nursing Program and Services. b. Provide Patient Care (3) Implement Patient Care (d) Coordinate Patient Care: As one of the principal care providers, the ambulatory care Nurse will assist the patient to receive various services to maximize the patient's well-being. Conplianco Criteria In You Part No “/3 Comments A. Ambulatory care nursing shall function as an integral part of the health team and use resource agencies to provide a continuum of care. B. The ACN shall inform the patient of referral systems, appointment routines, contract care regulations, Patient's Rights, and utilization of the health program and community resources. C. Ambulatory care nursing staff shall make appropriate referrals to other departments, health care delivery systems, IHS and tribal community health nurses, community health representatives and/or alternate resources. D. The referral shall include sufficient information to provide safe and effective continuing care. 59 FUNCTION: 3 Operate the Ambulatory Care Nursing Program and Services b. Provide Patient Care (3) Implement Patient Care (e) Document Care: Nursing documentation shall reflect the use of the nursing process. Compliance Crltoril In Yes Part No u/A . Comments A. Nursing care, including assessment, diagnosis, plan, implementation and evaluation shall be documented in the health record. B. Nursing documentation shall be legible, accurate, appropriate and timely. C. Nursing documentation shall reflect patient responses, the status of the patient and outcomes. D. All nursing documentation shall be signed, using first initial, last name and title. 60 FUNCTION: 3 Operate the Ambulatory Care Nursing Program and Services b. Provide Patient Care (4) Evaluate Care: ACN shall evaluate and modify the plan of care based on patient responses and attainment of patient goals. Compliance Criteria In Yes Part “In Cements A. Current data about the patient shall be collected, recorded and used to measure progress toward expected outcomes. The patient, significant others and members of the health care team contribute to the evaluation of patient care. Evaluation of ambulatory care and emergency room care shall be based on expected outcomes. Evaluation findings shall be used as a basis for assessment, nursing diagnosis and plan revision. Patient complaints regarding nursing care shall be documented and carefully reviewed and evaluated. 61 FUNCTION: 3 Operate the Ambulatory Care Nursing Program and Services c. Initiate and Conduct Special Studies for Improvement of Patient Care: Ambulatory care nurses shall participate in special studies and research activities for the purpose of improving the quality of patient care given and to expand the body of nursing knowledge. Compliance Yes Part MIA Comments A. Director of ambulatory care nursing shall encourage and facilitate research in the practice setting. B. Ambulatory care nursing shall participate in research to expand the body of knowledge related to ambulatory care and emergency room nursing. C. The ambulatory care nurse shall collaborate with colleagues who are engaged in research in the practice setting. D. Research activities shall be performed in accordance with professional practices, legal requirements, 133 policy and tribal approved. E. Research activities shall be appropriate to the expertise of the staff and the resources of the organization. F. The rights and welfare of patients involved in research shall be adequately protected. G. Informed consent of the patient, in the language spoken, is obtained through appropriate methods. E. Ambulatory care nursing shall utilize information from research literature and studies to improve practice. 62 FUNCTION: 3. Operate the Ambulatory Care nursing Program and Services d. Act as patient advocate in the health care system. ACN shall initiate and support actions which take into consideration the patient's decision and are consistent with sound health practices. Compliance In Criteria Yes Part No N/A “manta A. There shall be provision for patient input (i.e., community advisory board, solicitation of patient preferences and perceived needs, documentation of comments). ACN shall seek out resources and shall assist individuals and families in their use. There shall be promulgation of the Patients' Bill of Rights. There shall be a system for the ACN to communicate with other disciplines and agencies. ACN shall interpret agency policy to the patient. Patient care areas should be readily accessible to patients including the handicapped. Patient input shall be be evaluated by ACN and appropriate action taken. ACN shall facilitate communication between patients, families, and other health care providers for the purpose of management of patients' care. 63 FUNCTION: 4. MONITOR AMBULATORY CARE NURSING PROGRAM PERFORMANCE; The ambulatory care nursing service shall monitor its activities and related activities of other health program components to assure compliance with and appropriateness of standards, policies and procedures. Criteria Compliance Yes Part “In Comments Nursing achievement regarding philosophy and objectives shall be appraised annually with participation by ACN staff. The ACN service standards, policy and procedure manuals shall be reviewed annually. The quality and appropriateness of nursing care provided shall be monitored. Monthly administrative meetings will be scheduled with ACN staff to discuss ways to improve nursing service. 1) Minutes of meetings shall reflect participation by staff and shall be signed by the recorder. 2) Minutes of meeting shall be available to staff. 3) Attendance records of meetings shall be maintained. The management of ACN activities shall be monitored to assure compliance with standards, policies and procedures. The DACN/ACN will prepare and submit monthly reports to immediate supervisor with copy to Area Nursing Branch. , 64 FUNCTION: 4. Monitor Ambulatory Care Nursing Program Performance:(continued)) Criteria Compliance Yes In Part MIA Chm-ants The DACN/ACN will keep the ambulatory health director and/or Service Unit Director informed regarding development, progress or changes in the AER program. Services will be reviewed and modified to keep pace with current health needs. Priorities shall be reviewed and updated annually. Health records shall be audited for compliance with nursing standards. Physical layout of the facility is periodically reviewed to determine if space continues to be appropriate for patient services. Policies and Procedures for maintaining safe operation of all equipment are reviewed and updated at least annually. Research activities shall be monitored periodically. Ambulatory care and ER services shall be monitored according to established criteria and will include the following: 65 FUNCTION: 4. Monitor Ambulatory Care Nursing Program Performance:(continued) Criteria Compliance YBS In Part “/3 comments l) Ambulatory Care a) Health maintenance. b) Communicable disease. c) Acute illness. d) Chronic illness. 2) Emergency Services. a) Hospital admissions. b) Codes. c) Transfers. O. The medical protocols/standing shall be reviewed annually and as staff changes occur. 66 FUNCTION: 5. EVALUATE AMBULATORY CARE NURSING PROGRAM: The ambulatory care nursing program shall be evaluated to determine the effectiveness and efficiency in attaining objectives, the appropriateness of the objectives, and the adequacy of the program to accomplish the purposes of ambulatory care nursing. Criteria In Compliance Yes Part No “/3 Comments A. c. D. Statement of philosophy, goals and objectives shall be evaluated. Guidelines and practices of ACN programs shall be evaluated. Evaluation of clinical experience for ACN staff and students shall involve the DACN/ACN. Regularly scheduled administrative meetings with ACN staff shall be held to discuss and evaluate services. Records, reports, and workload data shall be analyzed by ACN staff in order to evaluate the overall community ambulatory care nursing program. Priorities for ACN services shall be evaluated. An annual report shall be submitted by the DACN/ACN and shall contain information relating to: 1) Progress in achieving program plan goals. 2) Achievement of established goals. 3) Highlights of the year. 4) Plans for the future. 5) Workload and staffing statistics 67 FUNCTION: 5. Evaluate Ambulatory Care Nursing Program (continued) Criteria Compl lance Yes In Part MIA Comments H. I. J. K. The evaluation of administrative, supervisory and patient care practices shall be done by the the DACN/ACN as an on-going activity at the health program level and done annually by the Area Nursing Services. An evaluation of staff performance shall be done according to policy. Evaluation and counseling sessions shall be ‘held at least annually with each member of the staff to discuss strengths and weaknesses and elicit suggestions for improvement. Evaluations will include availability and utilization of resources, quality of services by structure, process, and outcome; and costs as appropriate and practical. The evaluation process shall include review of the 'following: 1) Written protocols defining minimum standards for the management of specific problems and for preventive measures for all categories of patients. 68 FUNCTION: 5. Evaluate Ambulatory Care Nursing Program (continued) Criteria Compliance You In Part Illa Comments M. N. 2) nursing audit procedures which measure practice performance against pre-defined standards. 3) The mechanism for follow-up of patient grievances. 4) Data. Evaluation shall be performed utilizing the medical record and pre-established criterion for the following: 1) Patient transfers. 2) Hospital admissions from the ER or ambulatory care service. 3) Emergency codes. Standards of Performance will be evaluated annually. 69 FUNCTION: 6. MANAGE AMBULATORY CARE NURSING PROGRAM RESOURCES: 'The ambulatory care nursing program shall manage its equipment, facility, dollar and human resources to assure they are maintained at required standards and are allocated, distributed, or utilized optimally. Criteria Compliance Yes In Part “/5 Comments G. All position and billet descriptions with standards of performance for staff under ACN supervision shall be written, current, available, and maintained in the ACN office. Written standard of performance for each position outlining specific responsibility shall be updated annually. Recruitment, selection, assignment, retention and promotion of ACN personnel shall be based on individual qualifications, capabilities, and standards of the profession and organization. Appropriate personnel action shall be taken for less than satisfactory performance. Current clinical privileges shall be delineated, documented and communicated to key facility staff for all levels of ACN staff. "Rewards" shall be sought for staff, i.e.: l) Increments (within grade increases). 2) Incentive awards (plaques). Qualified staff shall be encouraged to become increasingly independent in action as their skills and knowledge increase. 70 FUNCTION: 6. Manage Ambulatory Care Nursing Program Resources: (continued) Criteria complianc. Yes In Part MIA Cal-ants J. The DACN/ACN shall recommend staffing patterns necessary to meet changing health needs. Number and mix of ACN staff, professional and ancillary, shall be according to demon- strated need and IE8 Resource Requirements Methodology. There shall be a written orientation plan which includes those items identified in the IHS ACN Orientation Guide and the following: 1) Time frames for completion. 2) Plan to meet skills deficiency. 3) Personal adjustment guides to new area, city or reservation. 4) Supervisor for staff member or to whom he or she is responsible. 5) Information on daily work activities including collaboration with hospital and community nursing services. 6) Orientation experience with a community health professional including home visits. 7) Supervised experience prior to being left "in charge". In-service training shall be provided at least monthly for ACN personnel. There is on—going relevant in—service and continuing education which is documented. Such program shall include at minimum: ....._..-...1_ 71 FUNCTION} 6. Manage Ambulatory Care Nursing Program Resources: (continued) Compliance Criteria In Yes Part N/A Co-ents 1) Safety. . 2) Infection control. L 3) CPR. ' 4) Deficiencies identified through QA studies. Professional books, current periodicals, audio—visual equipment, and appropriate teaching tools shall be readily available. ACN staff shall be encouraged to engage in continuing education programs and in activities for self-improvement. There shall be regularly scheduled administrative meetings with ACN staff to discuss ways to improve ' utilization of resources. Additional reports to pinpoint problems,\ personnel utilization, program accom- plishment, etc. shall be developed from information received from health program data. Position description shall reflect educational and experimental requirements. Current career plan shall be on file for each employee. 72 STANDARD STANDARD STANDARD STANDARD _ STANDARD ‘ STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD II III IV VI VII VIII IX XI XII APPENDIX I AMERICAN NURSES ASSOCIATION STANDARDS FOR NURSING SERVICE (1973) Nursing administration has a philosophy and objectives which reflect the purposes of the health care organization and give direction to the Nursing Care Program. Nursing administration has the responsibility and authority for the quality of nursing practice within the health care organization. The Nursing service has a designated leader who is a qualified registered nurse and a member of the operational policy—making bodies of the health care organization. The nursing care program is integrated into the total programs of the health care organization. Nursing administration determines the budget necessary to carry out the nursing care program and administers the approved budget. A nursing service organization plan delineates the functional structure of the department and shows established relationships among nursing personnel and with other services. The Nursing Administration has written personnel policies which assist in recruiting and maintaining a qualified staff. Nursing Administration shall detail guidelines for utilization of nursing personnel. The Nursing Administration provides programs for orientation and continued learning of nursing personnel. A nursing service has the responsibility to participate in the education of students in the health care field. A nursing service supports research in the health care field. A nursing service evaluates its clinical and administrative practices. 73 PRACTICE STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD STANDARD RESEARCH STANDARD II III IV VI VII VIII APPENDIX II IHS STANDARDS FOR AMBULATORY CARE NURSING SERVICE (1984) Ambulatory care nurses shall possess current comprehensive knowledge and skills in ambulatory care nursing. Ambulatory care nurses shall initiate collection of data pertaining to physical and psycho-social status of the patients. The.collection is systematic, pertinent and ongoing. Ambulatory care nurses shall analyte health status data to formulate a nursing diagnosis. Ambulatory care nurses shall formulate a comprehensive nursing care plan for the patient and collaborate in the formulation of the overall patient care plan. Ambulatory care nurses shall implement a plan of care. Ambulatory care nurses shall evaluate and modify the plan of care based on observable responses of patients and attainment of patient goals. Ambulatory care nursing documentation shall be accurate, appropriate, legible and timely. Ambulatory care nurses shall provide care based on philosophical and ethical concepts such as a reverence for life and a respect for the inherent dignity, worth, autonomy, and individuality of each human being, and on a resolution to act dynamically in relation to people's beliefs. Ambulatory care nurses shall promote open and timely communication with patients, their significant others, and team members. 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