Ateneo de Davao University

Graduate School

Name: Dennis N. Muñoz, LPT, RM, RN Course: Nsg 707- Nursing Leadership & Administration
Degree: Master’s in Nursing Professor: Dr. Patria V. Manalaysay, RN

FINAL COURSE REQUIREMENT

As a nurse manager, nurse administrator, design what your unit will be like, by identifying issues and concerns, related to
management processes areas to improve on, and your action plan.

Functional Rationale Key Targe Organization Financial Monitoring Frequency

Objectives Performance t Responsible Contingency Tool of
Indicator Plan Monitoring
1. To ensure A patient Percentage of 98 % All Nursing Annual Patient Monthly
patient satisfaction admitted Units with Budget per Satisfaction
satisfaction survey is a set of satisfied patients admitted department Survey adapted
in nursing questions used patients from Fongwa
service to collect including (2007) is initated
feedback from Intensive Care prior to
patients to unit discharge of the
measure their Percentage of 98% Emergency patient Monthly
satisfaction with satisfied patient Department
the quality and in receiving from and
care of the emergency Outpatient
healthcare Department or Department
service provider. Out patient
The patient department
satisfaction
survey
questionnaire
helps adjudge
 basic metrics
across patient
care that aid
medical
institutions
particularly in
the nursing
service in
understanding
the level of care
provided and
pitfalls in service.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Monitoring
Plan
3. To ensure A medical chart Percentage of 95% Nurses of all Annual 1. Patient’s Monthly
completenes is comprised of complete record Units Budget per Chart
s of medical notes of a patient’s key department 2. Checklist for
outpatient made by a clinical data and completenes
and admitted physician, nurse, medical history, s of the
patient’s lab technician or such as patient’s
chart upon
any other demographics, chart
discharge
member of a vital signs, 3. Admission
patient’s diagnoses, and
healthcare team. medications, discharge
Medical chart treatment plans, logbook
abstractions progress notes, 4. Medical
provide useful problems, records QQA
first steps in immunization (Qualitative
assessing dates, allergies, and
differences in the radiology Quantitative
 quality of images, and analysis)
hospital care for laboratory and findings not
patients in test results. complied
various medical within 24
condition. hours
Accurate and
complete
medical charts
ensure
systematic
documentation
of a patient’s
medical history,
diagnosis,
treatment, and
care.
Functional Rationale Key Performance Target Organization Financial Monitoring Frequency of
Objectives Indicator Responsible Contingency Tool Monitoring
Plan
4. To ensure Administering Percentage of 0% Nurses of all Annual 1. Medication Monthly
safety in medication is a medication error Units Budget per error
giving crucial nursing per department department Monitoring
medication responsibility. To Tool
ensure safe and 2. Patient’s
effective drug chart
therapy, the
nurse must be
familiar with
indications, the 5
rights: right
patient, right
 drug, right dose,
right route, and
right time. Each
patient must be
assessed before
administration,
and the
medication
should be
delayed or
withheld if
indicated.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Plan Monitoring
5. Maintain The critical Percentage of 95% Housekeeping Annual Patient Monthly
cleanliness aspects of the patient personnel – Budget per Satisfaction
and cleaning and satisfied with general department Survey adapted
sanitation of disinfection hospital orderly from Fongwa
the facility programs cleanliness, (2007).
include the orderliness and
availability of sanitation.
cleaning
schedules and
procedures for
timely and
effective hospital
routine cleaning
by designated
personnel;
provision of
effective
 cleaning and
disinfecting
agents that are
not detrimental
to hospital
facilities
materials;
appropriate
personal
protective
equipment; and
adequate
training for
designated
personnel.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Plan Monitoring
6. To transport A patient safety Accident/incident 0% Housekeeping Annual Incident report Bi-Monthly
patient safely incident is any rate monitoring personnel – Budget per
without unplanned or medical department
Accident unintended orderly;
event or Nurses of All
circumstance units
which could
have resulted or
did result in
harm to a
patient. This
includes harm
from an
outcome of an
 illness or its
treatment that
did not
meet the
patient’s or the
clinician’s
expectation for
improvement or
cure.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Plan Monitoring
7. To provide To help rid linens Percentage of 95% Central Annual Patient Bi- Monthly
patients with of bacteria, patients satisfied Supply Budget per Satisfaction
complete, hospitals should with complete, Department department Survey adapted
clean, and be sure their clean, and from Fongwa
sanitized washing process sanitized linens (2007).
linins
closely follows and packed
including
laundry toiletries
package
guidelines from designed for in-
toiletries
the Department patient.
of Health (DOH).
Per the agency,
the laundry cycle
should consist of
a flush, the main
wash, a bleach
cycle, a rinse
cycle and a
souring cycle.
Even if the
patient is
 assigned as an
in-patient, it is
pleasant to be
able to freshen
up and will help
patient to feel
more
comfortable with
clean pack
toiletries.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Monitoring
Plan
8. To ensure all Medical Percentage 90% Property Annual Monthly Monthly
nursing equipment is an inventory of fully custodian and Budget per Logistics
service essential health functional Logistics department Checklist
equipments intervention tool equipment per
are fully used by nurses nursing
functional – for prevention, department
BP, Cardiac
diagnosis, and
Monitor,
treatment of
Suction
disease and for
machine,
Mechanical rehabilitation of
Ventilators patients. Critical
shortage of
medical
equipment at
the hospital
occurred in the
form of
unavailability of
 equipment, low
quality, and poor
maintenance of
the few that
were available.
Shortage
impacted
negatively on
nursing care,
nursing
profession and
the hospital.
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Monitoring
Plan
9. To ensure adequate Staffing FTE – 90% Human Annual Staffing schedule Monthly
that Patient- numbers of measure of work Resources Budget per
Staff Ratio licensed committed of Department department
are registered full-time and Nursing
proportional nurses, licensed employee Services
within the practical nurses, 1.0 FTE = works Department
limits
and other 5 days/week,
personnel to 8 hours/day
provide nursing
care to all *Due to COVID
patients as 19 skeletal work
needed. There force is initiated,
must be to reduce
supervisory and exposure days
staff personnel with the patient
for each by increasing the
 department or number of hours
nursing unit to to 12 hour shift
ensure, when rotation in 4 days
needed, the off period,
immediate however
availability of a healthcare
registered nurse institution must
for bedside care be adherent to
of any patient. Forty Hour
Week Law –
based on RA
5901
Functional Rationale Key Performance Target Organization Financial Monitoring Tool Frequency of
Objectives Indicator Responsible Contingency Plan Monitoring
10. Reduced Nurse retention Percentage of 90% Human Annual 1. Percentage Monthly
Employee can save a Nursing Resources Budget per of Nursing
Turnover hospital the performance Department department performance
Rate expense and done monthly and Nursing 2. Stress Level
cost of filling and quarterly Services and Work
open nursing Department Satisfaction
positions Stress Level and Assessment
recently vacated. Work Satisfaction Record
This expense Assessment
includes Record done
advertising and monthly and
recruiting costs, quarterly
orientation and
training costs,
and the lower
productivity of a
newly hired
nurse.
Methodology
Since the announcement of the Professional Regulation Commission on September 18, 2020 (Friday), I decided to
apply as a staff nurse at Tagum Doctors Hospital. I am fortunate that I landed as a staff nurse in the ICU as a trainee
starting September 21, 2020. I am privileged to be hired because my primary intention aside from the remuneration I
received monthly, is to obtain hospital exposure and to relate what I have learned in the Master of Nursing Program in
Nursing Administration. I interviewed the Chief Nursing Officer (designate) on October 15, 2020, to obtain a summary of
various hospital issues, problems, and concerns within the realms of the nursing service department and I came up with 9
common issues. The problems were uniformly distributed in all hospital departments therefore specific problems were no
longer identified. I seek information on whether the hospital has an action plan in the nursing service department but
unfortunately, the institution does not an input.

How did I come up with the planning matrix?

I used to work as a School Nurse way back in 2017 up to 2019 at Liceo de Davao and we used to do 3-year
School’s Improvement Plan (SIP). Therefore, I borrowed the planning matrix of the Department of Education and modified
the content of the matrix process, in which the format is applied in the hospital setting, thus the writer developed the
Annual Hospital Improvement Plan.