Nursing Standards of Care
The Nursing Standards of Care was established as an independent directorate within Nursing Services on the 1st of March, 2011. It initially functioned with one team of nurses focusing on clinical audits. While teams such as Nursing Informatics, Pain Management, and Nursing medication Safety existed then, they were not under the Nursing Standards of Care directorate. Over the years, various other specialized teams were established.
As of March 2021, all now function under the umbrella of Standards of Care with the primary function of improving the quality of nursing care across all facilities in the central region.
The teams include the following:
Nursing Quality Improvement Service (NQIS)
The Nursing Quality Improvement Service (NQIS) was established in 2016 as part of the Nursing Transformation Program within the Ministry of National Guard-Health Affairs (MNGHA).
The NQIS supports Nursing Services to develop and build upon its ability, accountability, and capacity to drive continuous quality and safety improvement for all patients receiving care through MNGHA-Riyadh.
In February 2019, the service merged with the Standards of Care (clinical audit) team. It consisted of a Nurse Specialist and four Quality Improvement Nurses.
NQIS Services:
- Clinical Audits and Improvement Initiatives.
- Fall Prevention and Management.
- Accreditation Readiness.
- Development of nursing quality measures.
- Site facilitation for the National Database of Nursing Quality Indicators (NDNQI).
- Nursing Staff Survey Support.
- Support hospital Quality Improvement Department events and activities (e.g. safety culture surveys, excellence and innovation events).
- Educational activities for clinical staff related to quality improvement science.
- Arrange nursing publications and conferences.
- Collaborate with Clinical Teams and the Quality Management Department in incident management and action planning for improvement.
- Participate in clinical risk identification through Failure Mode and Effect Analyses (FMEA) and Multi-disciplinary Environmental Rounds.
NQIS Goals and Achievements:
- Implement a standardized Adult Fall Prevention Standards of Practice Audit program in all adult inpatient areas across KAMC and KASCH and collaborate with other MNGHA regions to standardize processes to prevent harm from patient falls.
- Implement a standardized Pediatric Fall Prevention Standards of Practice Audit Program in all Pediatric in-patient areas across KAMC and KASCH.
- Ensure Standards of Practice Audit methodologies are developed and approved by Nursing Services.
- Implement and analyze the NDNQI Registered Nurse Satisfaction survey 2021 and yearly thereafter.
- Utilize digital technology to streamline the NQIS General Nursing Orientation education sessions.
Nursing Medication Safety Team (NRMST)
The Nursing Medication Safety Team (NRMST) was established in 2010, with only one member representing nursing in the Central Region Medication Safety Program, established in 2007. The NRMST's scope of services expanded over the years. In 2019, the number of staff assigned to the team increased, including a Nurse Specialist and two Medication Safety Nurses.
The main focus of the NRMST is to enhance safe medication use processes among all nurses in MNGHA-Central Region. The team works in a collaborative partnership with different clinical and non-clinical departments, supporting nursing services towards medication safety and enhancing safer systems and error prevention and reduction in care delivery.
NRMST Services
- Coordinate nursing medication safety activities.
- Educate nurses on system-based causes for medical errors and effective preventative measures.
- Promote and apply best standards in medication management.
- Implement action plans and quality improvement projects as clinically indicated.
- Participate in multi-disciplinary medication safety projects.
- Conduct nursing rounds to review nursing clinical practices in relation to medication administration.
- Analysis of all medication administration safety reports and make recommendations for learning and improvement.
- Represents Nursing Services on Saudi Medication Safety Center, Medication Safety Program and Pharmacy and Therapeutics committees.
NRMST Goals and Achievements
- Achieve Zero harm during medication administration process.
- Increase the infusion device drug library compliance rate to 95% and above.
- Implement quality improvement projects and action plans as clinically indicated. (e.g. Vancomycin Project, Safe Independent Double Check campaign, Saudi Medication Safety Center Audits).
Nursing Informatics (NI)
The Nursing Informatics Team was established in 2005 under Nursing Resource Systems. As the service developed and technology advanced, the team expanded in 2015 and now includes a Nurse Manager and seven Informatics Nurses.
Nursing informatics is a high-level technical field where data and technology are used daily to monitor systems, programs, patient care, and treatment activities. Data analysis enables us to see what’s working and what isn’t. These findings guide improvements and effects change that positively impact patients.
The NI team is passionate about what we do. We motivate developing, implementing, and optimizing electronic medical and health records through intelligent training methods and practical education as needed.
Since the end user is at the core of care, we keep them abreast of the latest system and software enhancements, providing support and education while seeking opportunities for their valuable feedback.
NI Services
- Provide education on all IT systems used by nurses.
- Provide IT support to all nurses.
- Coordinate information technology and healthcare activities.
- Troubleshoot all system issues.
- Interface monitoring.
- Participate in the development, implementation, solutions and innovation new project across all regions in MNGHA.
- Participate in product evaluation process related to IT devices used in patient care.
- Design and modify systems in order to meet the accreditation standards.
NI Goals and Achievements
- Lead nursing in digital transformation through automated workflows and clinical pathways.
- Implementation of automated medication dispensing, closed loop medication administration / specimen collection / blood transfusion administration using barcode scanning technology to eliminate the risk of errors that lead to patient harm.
- Drive and support the establishment of Nursing Tele-health (Virtual Outpatient Clinics).
- Completion of the CNE (Center for Nursing Education) e-registration System.
- Development of an e-staff file for nursing employees.
Wound and Ostomy Care Service (WOC)
The Wound and Ostomy Care service is a highly specialized team comprising 2 Nurse Specialists, 2 Clinical Resource Nurses (CRN), and four staff nurses highly trained in wound care management, ostomy care, and hospital-acquired pressure injury prevention (HAPI).
The role of the wound care nurse was introduced to ensure that patients requiring advanced wound management, ostomy care, and education or at risk of developing hospital-acquired pressure injuries were managed by skilled clinical nurse experts and that these experts could improve the level of the wound and ostomy care across the organization for both inpatients and outpatients.
Services Provided
- Pre-operative stoma marking and education to patients
- Consultation for post-operative stoma care and troubleshooting problems
- Discharge education to patients
- Report monthly Key Performance Indicators
- Coordinate HAPI prevalence surveys across KAMC and KASCH every 3-6 months, benchmarking performance with other national and international organizations participating in the National Database for Nursing Quality Indicators (NDNQI)
- Maintain a comprehensive database on HAPI incidents and quality improvement programs including validation, analysis and investigation of a reported HAPI events.
- Lead Quality Improvement and research initiatives into the reduction of HAPI and the improvement of wound management across MNGHA-CR.
- Manage the outpatients nurse lead ostomy and wound care clinics
- Receive referrals from clinical teams for wound assessment, advice and recommendations for wound types.
- Improve the multidisciplinary teams knowledge and skill in relation to wound and ostomy care
- Provide consult and troubleshooting services for negative pressure wound management devices
- Audit and monitor pressure injury assessment and documentation
- Evaluate and recommend wound care products and equipment for prevention or management of wounds
Goals and Achievements
- Reduction in Hospital Acquired Pressure Injury prevalence and incidence year on year
- Complete formal wound care training for all nurses through unit-based education sessions and through formal education services in the Center for Nursing Education
- Provides education to all nurses in MNGHA through the ‘LEAD in Nursing’ program: Wound and Ostomy Care Course.
- Improve compliance of the hospital acquired pressure injury pathway in the Hospital Information System (HIS) / electronic patient record.
- Complete training for home health care employees and all surgical units in KAMC on Negative Pressure wound therapy (NPWT)
- Ensure that there is sufficient resources of selected wound care products and pressure relieving equipment such as air-loss mattresses, available within the organisation for high risk patients.
Nursing Pain Management Service
The Nursing Pain Management Service was established in 2003 in King Abdulaziz Medical City Hospital, Central Region, within MNGHA. In 2006 after the first JCI accreditation, pain management services were positively recognized. They were prioritized as a mandatory standard to be met for comprehensive care delivery by all health care providers. This resulted in gaining accreditation as a pain center by a major accrediting organization.
The Pain Management Nursing Team (PMT) was reconfigured in 2008 for nurse-led assignments of different pain nurse responsibilities to meet the organization's needs. The Team includes three categories of nurses with varying scopes of function: Nurse Specialist, Clinical Resource Nurse, and 4 Staff nurses.
In 2015 the PMT expanded its activities by covering the units in KASCH. Today, the scope of the Pain Nursing Management Service has expanded from adult patients to include pediatric patient services covering all nursing areas through the Patient Care in Partnership Model.
NPM Services
Pediatric and Adult Acute Pain Services: Pain nurses and Physicians manage patients receiving advanced pain modalities: Patient Controlled Analgesia (PCA), Epidural Analgesia, Peripheral Nerve Blocks (PNB), Intra-thecal Morphine, Continuous Morphine and other patients experiencing uncontrolled acute types pain. This includes screen, assess, reassess and provide education to patients and family in managing all types of acute pain comprehensively.
Chronic Pain Service: Supports nursing staff for all types of chronic pain in assessment, reassessment, patient and family education and multimodal interventions, and collaboration with Physicians and Outpatient, Clinic Nurses and other multidisciplinary teams involved in the patients’ care.
Palliative Pain Service: Pain nurses conducts pain nurse rounds and attend the patients escalated by nursing staff for patient with uncontrolled pain for further assessment, patient and family education, collaborate with other multidisciplinary teams for recommendations of effective pain interventions.
- Patient Care in Partnership Model by collaborating with all nursing units in KAMC and KASCH for pain management.
- Monitor and measuring pain management nursing care standards utilizing clinical audits methodologies as part of key quality performance measures.
- Benchmarking pain management standards and practice in KAMC and KASCH with international hospitals through National Database for Nursing Quality Indicators (NDNQI).
- Updating pain management nursing care policies and procedures as per accreditation standards and evidenced based practice.
- Education of patient and family, and empowerment of nursing staff are core competencies of NPMT.
NPMS Goals
- Improving Nurses’ advocacy for use of a Balanced Analgesic Stepladder for Pain nursing Interventions both KAMC and KASCH through serial unit based education and to all nurses in MNGHA through formal education in the ‘LEAD in Nursing’ program: Essential Principles of Pain Management course.
- Optimizing pain control to satisfactory relief levels (no pain to mild pain) for patients through of the use of multimodal analgesia that enhances balanced analgesia and measured by patient-oriented pain prevalence surveys.
Tracheostomy Management
The adult tracheostomy service was created in 2012 to support improving the management of tracheotomized patients in KAMC-CR. The program aims to ensure that nurses have resources to assist with tracheostomy concerns and issues and ensure that outpatient and inpatient tracheostomy patients are managed with the best practice standards.
The team currently consists of 2 Clinical Resource Nurses (CRN) (1 Adult and 1 Pediatric) and 1 Staff Nurse working collaboratively in the tracheostomy team, with a multidisciplinary team consisting of an ENT surgeon and respiratory therapist.
Services Provided
Members of the ENT tracheostomy team conducting bi-weekly rounds of referred tracheostomy patients
Conducts weekly ENT and weekly trache clinic with ENT surgeons
Troubleshooting nursing issues related to tracheostomy care
Follow-up and analysis of tracheostomy related clinical incidents
Creates and reviews tracheostomy related policies and competencies
Conducts educational sessions and workshops related to tracheostomy education, particularly focusing on areas where educational deficits are identified
In conjunction with standards of care, coordinates, participates and assesses bi-yearly quality audit programs
Generates monthly Key Performance Indicator (KPI) reports.
Goals and Achievements
Create a virtual training program as an alternative option to face to face education to ensure better access to the fundamentals of tracheostomy care program
Increase the percentage of tracheostomy patients that can be safely weaned from oxygen prior to discharge to >80%.
Code Blue Management
Adult code blue services were established in 2013. The support service ensures that all aspects of cardiopulmonary resuscitation outside of Critical Care areas in KAMC-R are of the highest quality and that all equipment utilized during resuscitation is appropriate and maintained according to standards and requirements.
The service also ensures that staff involved in basic life support (BLS) and Advanced Cardiac Life Support (ACLS) have the appropriate competencies and their skills are of the highest possible standards. The service consists of a Clinical Resource Nurse (CRN) and 3 Staff Nurse 1 positions.
Services Provided
- Creation and revision of all code blue related policies and competencies.
- Maintaining and reviewing code blue response zones to ensure timely cardiac arrest team responses across all areas of the facility.
- In conjunction with Nursing Quality Improvement Service, ensures that the crash cart ‘ready for use’ audit is conducted quarterly and that the report of findings is escalated to nursing Directors with action plans for Improvement.
- Conduct multidisciplinary Code Blue simulation sessions to ensure, timely response, effective teamwork within the Code Blue response team and appropriate knowledge of ACLS guidelines.
- Provide support for CRN/Nurse Manager related to BLS and ACLS requirements.
- Participate as an active team member of the Hospital CPR committee.
- Report and review monthly Key Performance Indicators (KPI) for the service.
- Provides consultation services for identifying crash carts requirements as part of commissioning of new clinical services or departments.
- Training and assessment of all nursing code blue responders.
Goals and Achievements
- Ensure that there is 100% compliance with use of the Automated External Defibrillator (AED) mode in all code blue events in non-critical care arrest situations.
- Led in establishing and maintaining a development program to enable trained code blue nurse responders to administer first dose of epinephrine and insert Intraosseus cannulae during cardiac arrest when this is indicated.
- Develop a program for the continuous reassessment of nursing code blue responders to be undertaken yearly to ensure that the nursing code runners are of the highest possible standards.
