1 - The Standard Operating Procedures (SOPs) and/or Normative Instructions
(NIs) are updated all over the institution |
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10 |
20.4 |
|
39 |
79.6 |
2 - Nursing SOPs and/or NIs are distributed among workers |
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10 |
20.4 |
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39 |
79.6 |
3 - There is a formal description of SOPs, NIs and/or nursing protocols
in the Nursing Manual |
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6 |
12.2 |
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43 |
87.8 |
4 - There is a Nursing Manual available and easily accessible for consultation
by the team. |
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8 |
16.3 |
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41 |
83.7 |
5 - Nursing SOPs and/or NIs are validated by the quality area |
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4 |
8.3 |
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15 |
31.3 |
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29 |
60.4 |
6 - Nursing SOPs and/or NIs are periodically reviewed |
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13 |
26.5 |
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36 |
73.5 |
7 - The assessment phase of the Nursing Process is applied |
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11 |
22.4 |
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38 |
77.6 |
8 - The diagnostic phase of the Nursing Process
is applied |
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2 |
4.2 |
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17 |
35.4 |
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29 |
60.4 |
9 - The care planning phase of the Nursing Process is applied |
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1 |
2.0 |
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10 |
20.4 |
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38 |
77.6 |
10 - The evaluation phase of the Nursing Process
is applied |
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10 |
20.4 |
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39 |
79.6 |
11 - The phases or model of the Nursing Process are applied in critical
areas such as the ICU |
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7 |
14.3 |
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42 |
85.7 |
12 - The phases or model of the Nursing Process are applied all over
the institution |
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4 |
8.2 |
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16 |
32.7 |
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29 |
59.2 |
13 - Information from the Nursing Process is used by the multidisciplinary
team |
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4 |
8.2 |
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12 |
24.5 |
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33 |
67.3 |
14 - There is evidence of the utilization of information from the Nursing
Process in the prescription of other professionals |
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7 |
14.3 |
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21 |
42.9 |
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21 |
42.9 |
15 - The use of the Nursing Process is articulated as a form of continuity
of care |
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2 |
4.3 |
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10 |
21.3 |
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35 |
74.5 |
16 - Nurses are responsible for their own practice and care coordination |
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2 |
4.2 |
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10 |
20.8 |
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36 |
75.0 |
17 - Nursing administration and management is visible in the institution |
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1 |
2.0 |
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8 |
16.3 |
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40 |
81.6 |
18 - The nurse specialist participates in the selection and acquisition
of hospital technology (equipment) for the workplace |
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1 |
2.0 |
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2 |
4.1 |
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13 |
26.5 |
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33 |
67.3 |
19 - There is evidence of assessment by the nurse manager for the technology
to be acquired in the institution |
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2 |
4.1 |
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2 |
4.1 |
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16 |
32.7 |
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29 |
59.2 |
20 - There is at least one nursing work group to improve processes and
institutional interaction. |
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2 |
4.1 |
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14 |
28.6 |
|
33 |
67.3 |
21 - Nurses participate in working groups (committees or commissions)
in general in the institution |
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1 |
2.0 |
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10 |
20.4 |
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38 |
77.6 |
22 - Nursing administration or management is available |
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1 |
2.1 |
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6 |
12.5 |
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41 |
85.4 |
23 - There is active participation (involvement and commitment) of the
nurse manager and nurse leaders in nursing administration |
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4 |
8.2 |
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4 |
8.2 |
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41 |
83.7 |
24 - The nurse manager is autonomous to make decisions about the work
processes |
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3 |
6.1 |
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6 |
12.2 |
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40 |
81.6 |
25 - The care processes that involve nursing are often analyzed and improved |
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2 |
4.1 |
|
4 |
8.2 |
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43 |
87.8 |
26 - The critical analysis and improvement of processes (e.g. non-compliance
and risk) identified by nursing are treated with a deadline |
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3 |
6.1 |
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10 |
20.4 |
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36 |
73.5 |
27 - Formal periodic meetings are held for the analysis of nursing work
processes |
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2 |
4.3 |
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10 |
21.7 |
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34 |
73.9 |
28 - Nurses use indicators to measure the quality of care |
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2 |
4.1 |
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6 |
12.2 |
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41 |
83.7 |
29 - The indicators of quality of nursing care are used to outline action
plans and improvement of processes |
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2 |
4.2 |
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6 |
12.5 |
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40 |
83.3 |
30 - The participation of the nursing team is encouraged to establish
actions and assess the outcomes. |
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4 |
8.2 |
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12 |
24.5 |
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33 |
67.3 |
31 - The nursing team is aware of who its customers and suppliers are |
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2 |
4.2 |
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18 |
37.5 |
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28 |
58.3 |
32 - There is a systematic and periodic update and/or improvement program
for the nursing team |
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1 |
2.0 |
|
9 |
18.4 |
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39 |
79.6 |
33 - The nurse manager has the autonomy to hire nursing workers |
1 |
2.1 |
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5 |
10.6 |
|
9 |
19.1 |
|
32 |
68.1 |
34 - Nurses have the autonomy to fire nursing workers |
1 |
2.1 |
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6 |
12.8 |
|
7 |
14.9 |
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33 |
70.2 |
35 - There is a formal program to integrate the new employee (nursing
professional) into the institutional service |
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1 |
2.0 |
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1 |
2.0 |
|
12 |
24.5 |
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35 |
71.4 |
36 - Patient's rights and privacy are respected in all hospital environments
by nursing, according to law |
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7 |
14.3 |
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42 |
85.7 |
37 - Nurses participate or act in the inpatient information system with
other professionals |
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15 |
31.3 |
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33 |
68.8 |
38 - The day/night cycle of inpatients is preserved by nursing |
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2 |
4.2 |
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21 |
43.8 |
|
25 |
52.1 |
39 - There is evidence that communication is effective in nursing |
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2 |
4.2 |
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15 |
31.3 |
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31 |
64.6 |
40 - Nurses know the most prevalent nosocomial profile in the institution
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5 |
10.4 |
|
21 |
43.8 |
|
22 |
45.8 |
41 - The institution has (multidisciplinary) clinical protocols used
by nursing based on evidence and on the nosocomial profile |
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1 |
2.1 |
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3 |
6.3 |
|
13 |
27.1 |
|
31 |
64.6 |
42 - Newborns are distributed according to severity by nursing. |
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2 |
4.3 |
|
10 |
21.7 |
|
34 |
73.9 |
43 - The nurse who is member of the hospital risk management committee
or group participates in decision making |
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1 |
2.1 |
|
15 |
31.9 |
|
31 |
66.0 |
44 - There is a system implemented for the management of adverse events
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1 |
2.1 |
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1 |
2.1 |
|
6 |
12.8 |
|
39 |
83.0 |
45 - Nursing implements actions against adverse events |
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2 |
4.2 |
|
6 |
12.5 |
|
40 |
83.3 |
46 - Nursing counts on safety and/or controlled access and/or continuous
surveillance in Pediatrics, Neonatal and Psychiatry areas |
|
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1 |
2.1 |
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4 |
8.3 |
|
14 |
29.2 |
|
29 |
60.4 |
47 - There is a system implemented for the management of infection risks
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1 |
2.1 |
|
8 |
16.7 |
|
39 |
81.3 |
48 - Nursing acts in partnership with the Commission for Infection Control
in epidemiological surveillance of infections |
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9 |
18.4 |
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40 |
81.6 |
49 - Nursing implements action against infection-related adverse events |
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1 |
2.0 |
|
11 |
22.4 |
|
37 |
75.5 |
50 - Nursing implements action against adverse events with blood components |
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2 |
4.1 |
|
13 |
26.5 |
|
34 |
69.4 |
51 - Nursing implements action against adverse events with equipment |
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5 |
10.2 |
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15 |
30.6 |
|
29 |
59.2 |
52 - Nurses control psychotropic drugs in the nursing unit |
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3 |
6.3 |
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11 |
22.9 |
|
34 |
70.8 |
53 - Nursing implements action against adverse events with drugs |
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3 |
6.1 |
|
8 |
16.3 |
|
38 |
77.6 |
54 - There is validation by nursing related to sterilization processes
in the Material and Central Sterilization |
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5 |
10.2 |
|
44 |
89.8 |
55 - There is a thermometer for temperature and humidity measurement
by nursing in the arsenal of the Material and Central Sterilization by nursing |
|
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2 |
4.1 |
|
8 |
16.3 |
|
39 |
79.6 |
56 - Nursing implements action in the absence of any instrument after
surgery in the operating room |
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1 |
2.0 |
|
15 |
30.6 |
|
33 |
67.3 |
57 - There is a system implemented for the management of environmental
risks in the institution |
|
|
|
1 |
2.1 |
|
4 |
8.5 |
|
23 |
48.9 |
|
19 |
40.4 |
58 - The pieces in the institution are comprehensively identified and
its outflow is registered and controlled by nursing |
|
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1 |
2.0 |
|
9 |
18.4 |
|
39 |
79.6 |
59 - Nursing follows the destiny of body parts to the environment, with
other areas |
1 |
2.1 |
|
2 |
4.2 |
|
14 |
29.2 |
|
19 |
39.6 |
|
12 |
25.0 |
60 - Nursing implements actions against adverse events with waste |
|
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|
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3 |
6.1 |
|
6 |
12.2 |
|
40 |
81.6 |
61 - There is an institutional system implemented for the management
of civil nursing responsibility risks |
1 |
2.1 |
|
|
|
|
2 |
4.3 |
|
16 |
34.0 |
|
28 |
59.6 |
62 - There is a contingency plan for unforeseen or unexpected events
in Nursing |
1 |
2.1 |
|
|
|
|
6 |
12.8 |
|
18 |
38.3 |
|
22 |
46.8 |
63 - Nursing implements action when there are contingent events |
2 |
4.1 |
|
|
|
|
1 |
2.0 |
|
17 |
34.7 |
|
29 |
59.2 |
64 - In the refrigerators of the nursing unit, there is complete identification
of what is stored |
1 |
2.1 |
|
|
|
|
1 |
2.1 |
|
9 |
18.8 |
|
37 |
77.1 |
65 - There is systematic control of the refrigerator temperature in the
nursing units |
|
|
|
|
|
|
1 |
2.1 |
|
10 |
20.8 |
|
37 |
77.1 |
66 - There is a systematic routine of cleaning and hygiene of refrigerators
used by nursing |
|
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|
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|
4 |
8.7 |
|
15 |
32.6 |
|
27 |
58.7 |
67 - Nursing management receives and analyzes customer assessments |
|
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|
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1 |
2.0 |
|
14 |
28.6 |
|
34 |
69.4 |
68 - Nursing management uses customer assessments to propose improvements
in processes |
|
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|
|
|
1 |
2.1 |
|
14 |
29.2 |
|
33 |
68.8 |
69 - There is articulation between the Hospital and the Nursing School
or College evidenced in care |
2 |
4.3 |
|
1 |
2.1 |
|
9 |
19.1 |
|
22 |
46.8 |
|
13 |
27.7 |