NURSE PRACTITIONER IN CRITICAL CARE POST GRADUATE RESIDENCY PROGRAMME

TAMILNADU NURSES AND MIDWIVES COUNCIL (CONSTITUTED UNDER TAMILNADU NURSES AND MIDWIVES ACT III&XXVI OF 1926&1960) Jayaprakash Narayanan Maligai, Old No: 140, New No: 56, Santhome High Road, Chennai 600 004 Tel.No:044-24934792, Fax No:044-24620547 Email: info@tamilnadunursingcouncil.com Web:www.tamilnadunursingcouncil.com INSEPECTION PROFORMA FOR NURSE PRACTITIONER IN CRITICAL CARE POST GRADUATE RESIDENCY PROGRAMME FOR THE GRANT OF RECOGNITION

TAMILNADU NURSES AND MIDWIVES COUNCIL (CONSTITUTED UNDER TAMILNADU NURSES AND MIDWIVES ACT III&XXVI OF 1926&1960) INSPECTION PROFORMA Is the institution willing to submit itself for the inspection under Rule No: 37 of Tamil Nadu Nurses & Midwives Act : Yes No (Please Tick the Appropriate Boxes) Type of Inspection : 1.Primary Inspection 3.Re- Inspection 5.Surpirse inspection 2.Annual Inspection 4.Enhancement of seats 6.Bi-annual Inspection 1. Name of the facilitator Designation and Address Phone No. Office: Inspector s Information Residence: Mobile No: 2 Name of the Member with Designation and address Phone No. Office: Residence: Mobile No: 3. Tamil Nadu Nursing Council Letter No. & date in which the Inspection Commission Constituted 4. Date of inspection 5. Academic Year

-2-1. GENERAL INFORMATION 1.Name of the Hospital : 2.Name Full Address with Pin Code: Telephone Numbers of the Hospital: Fax No. Telephone Numbers of College of Nursing: Fax No. Email Address : 3.NABH Accreditation Status :1.Yes 2.No if Yes Valid upto: Nursing excellence Certificate (to be Enclosed in Annexure I ) 4. Joint Commission International (JCI) Accreditation Status : 1.Yes 2.No. If Yes Valid upto: Nursing excellence Certificate (to be Enclosed in Annexure I ) 5. Name of the Trust/Society/Missionary/Company: (*Attested Copy of the Registered Trust/Society/ Missionary/Company to be enclosed in Annexure-II) 6. Administrative Control: 1.Central Government 2.State Government 3. Defense 4.Autonomous Body 5.PSU/Semu-Govt 6.Trust 7.Society 8.Company 9.NGO/Missionary 10. Private University 11.Deemed University 12. Govt.University 7.Name and Address of University to which affiliated? Telephone No of the University :

-3-8.Telephone No of the Registrar s: 9.Telephone No of the Controller of Examinations : 10. Number of Students Sanctioned by INC (Enclose the copy of the letter in Annexure-III) 11. List of Existing nursing and medical programmers in the Institution/University: S.No Nursing Medical I (i) (ii) (iii) (iv) (v) (vii) (viii) (ix) (x) (xi) (xii) Critical Care Nursing Courses 2.Any other Nursing Courses Critical Care Courses 1 DNB Courses 2. Any other Medical Courses related to Critical Care 12 Does the. Nursing Supdt/CNO/Nursing Director involved in 1.Yes 2.No (Planning/Policy/Budget Committee meetings verify)

13.FACULTY DETAILS : a. Professional qualification: Sl. No Designation Name 1. Professor-cum- GNM Principal B. Sc (N) M. Sc (N) Ph.D (N) 2. Professor-cum- Vice GNM Principal B. Sc (N) M. Sc (N) Ph.D (N) 3. Professor GNM B. Sc (N) M. Sc (N) Ph.D (N) -4- Name of the institution and university from where studied Date of passing

-5- Sl. No Designation 4. Reader/ Assoc. Professor Name GNM B. Sc (N) M. Sc (N) Ph.D (N) 5. Lecturer GNM 6. Tutor/ Clinical Instructor B. Sc (N) M. Sc (N) Ph.D (N) GNM B. Sc (N) M. Sc (N) Name of the institution and university from where studied Date of passing

-6- b. Current Employment details: Sl No Designation Name Age 1. Professor- cum- Principal 2. Professorcum- Vice Principal RN RM No. with Rene wal details P.F. UAN No. Pay scale Specialty Experience in years & months* Clinical Bef ore PG Teaching After PG Total Date of Joining Date of Leaving Previous Employment** & Institution Name Remarks 3. Professor 4. Reader/ Assoc. Professor 5. Lecturer 6. Tutor/ Clinical Instructor Enclose the copies of appointment order, a copy of relieving order of last institution, UG & PG Certificate, RN, RM & Additional Qualification, Registration Certificates & Experience Certificates Encl -------------- ** Check the Relieving order & enclose the same; if joined within 6 months **Provident Fund Universal Account Number

-7-14.1Number of existing staff in different CUs/CCUs S. Name of No 1 Medical GNM with 6 years of experience in CCU B.Sc (N) with 2 years of experience in CCU M.Sc (N) with one years of experience in CCU Ratio for ventilated patients Ratio for non - ventilated patients 2. Surgical GNM with 6 years of experience in CCU B.Sc (N) with 2 years of experience in CCU M.Sc (N) with one years of experience in CCU Ratio for ventilated patients Ratio for non - ventilated patients 3 Cardiac GNM with 6 years of experience in CCU B.Sc (N) with 2 years of experience in CCU M.Sc (N) with one years of experience in CCU Ratio for ventilated patients Ratio for non - ventilated patients 4 Cardio thoracic GNM with 6 years of experience in CCU B.Sc (N) with 2 years of experience in CCU M.Sc (N) with one years of experience in CCU Ratio for ventilated patients Ratio for non - ventilated patients 5 Neuro GNM with 6 years of experience in CCU B.Sc (N) with 2 years of experience in CCU M.Sc (N) with one years of experience in CCU Ratio for ventilated patients Ratio for non - ventilated patients Critical Care Unit/-Intensive Care Unit Day Shift Evening Shift Number of qualified staff in different shifts Night Day Evening Night Day Shift Shift Shift Shift Shift Evening Shift Night Shift

15.Details of Nursing Preceptors identified by the Hospital -8- S.No Name Qualification (Enclose photos with self-attestation and copies of certificates) 1 2 3 4 5 6 Name of posted No.of years of experience in Total No.of Years of Experience Salary PF UAN NO 16.Medical Preceptors Medical Preceptor: Intern visit/medical doctor with a postgraduate qualification working in a CCU. S.No Name Qualification (Enclose photos with self-attestation and copies of certificates) Name of posted 1 2 3 4 5 6 7 Preceptor : Refers to an experience and expert nurse or a physician working in a Critical care unit of a tertiary care center who provides practical/clinical Training to NPCC Students. No.of years of experience in Total No.of Years of Experience Nursing Preceptor : GNM With 6 Years Of Experience In CCU, B.Sc(N)with 2 Years Of Experience In CCU, M.Sc(N) with one Years Of Experience In CCU. Preceptor Student Ratio: 1.2 (Nursing and Medical)

-9- Particulars of External/Guest Faculty(Part Time)-Medical/Pharmacology. S.No Name Qualification Subject No. of hours per Year 1 2 3 4 5 6 7 Remarks II.PHYSICAL FACILITIES Infrastructure facilities available for NP program(lecturer hall minimum 300 sqt for 15 students) Class Room/Lecture Hall/Conference Room in Hospital No. of Students per Class Room Remarks 1. 2. 3. 4. Advanced Skill Lab in Hospital/College Computer Lab in 1.Yes Hospital/College 2.No. E. Learning Facilities 1.Yes 2.No. Library Facilities 1.Yes Each should have a mini library with 50 books. No. Students per Lab Critical care equipments and manikins to teach critical care skills One High Fidelity Manikin Mandatory with 2 beds / (List to be enclosed ANNEXURE- IV) For 10 students:3sets(reference 1 set,lending 2 Sets 75% of the INC prescribed books in all subject under NP Program 2.No. III.Budget a..is there a separate budget for the NP programs at the College: 1.Yes 2.No. Hospital: 1.Yes 2. No. b. Amount per annum : If Yes, give the name and designation: Of the drawing and disbursing authority:

-10- IV.Furnish the following details: S.No Particulars Expenditure 1. Salary-Teaching Faculty 2. Salary/Stipend for the Students 3. External Lecturers-for payment in accordance with the policy of the controlling authority. 4. New equipment and maintenance in skill lab 5. The Library maintenance, purchase of books, journals etc, 6. Computer lab-purchase of computers and accessories, maintenance. 7. Office supplies including stationery and postage 8. Contingencies N.B: Please attach last financial year s Audited Income and Expenditure Statement of the Institution(ANNEXURE-V) V.CLINICAL FACILITIES 1.Details of beds and staffing in CCUs/s 1.1 Beds and staffing in the hospital Total number of beds in the hospital (Pollution control board certificate of the hospital to be enclosed to verify the number of beds ANNEXURE VI) 1.2 Furnish the detailed list of Nurses with RN & RM Nos.(with renewal details) working in the Hospital(ANNEXURE-VII) Staffing: S.No Category of Staff Sanctioned posts In position 1. 1.C.N.O/N.S* 2. 2.D.N.S 3. 3.A.N.S.or D.S 4. Ward-in-charges /S.No 5 Staff Nurse /N.O 6 Total C.N.O=Chief Nursing Officer, N.S=Nursing Superintendent, D.N.S=Deputy Nursing Superintendent, A.N.S=Assistant Nursing Superintendent, D.S=Department Supervisor, S.N.O=Senior Nursing Officer, N.O=Nursing Officer * M.Sc(N)with 10 years of clinical experience including 5 years in Hospital Administrative Experience. OR * B.Sc(N) with 15 years of Clinical experience including 7 years in Hospital Administrative Experience.

Name of / CCU No.of Beds Occupancy on the day of Inspection* Average occupancy per month** No In- Charge Qufln Medical Surgical Cardi o Cardio thoracic Emergency/ Service.Unit Trauma ED& Disaster -11- Pediatric Neurology &Neuro- Surgical Dialysis Unit Staff Nurses (For 20 Beds (50% Ventilated 1:1ratio& 50% non ventilated Pts 1:2 ratio) Expected :15 nurses *3 shifts +45% Leave reserve) Day No Qualification Evening No Qualification Night No Qualification Burns OBG& Gynecology *Bed occupancy per day Calculation: Total No. of bed occupied *** Total No. Of patients ------------------------------ x 100 days in a month Total No. Of beds ------------------------ x 100 Available bed Days for 30 days Any Other & CCU Name of / CCU Medical Surgical Cardio Cardiothoracic Emergency/ Service.Unit Trauma ED& Disaster Pediatric Neurology &Neuro- Surgical Doctors Day No Qualification Evening No Qualification Night No Qualification NN.B: If separate (6-12) are not existing, then mention where patients belonging to such category are placed in the hospital Dialysis Unit Burns OBG& Gynecology Any Other & CCU

Nurse Patient Ratio Ventilated Patients Non Ventilated Patients Ventilated Patients Non Ventilated Patients Ventilated Patients Non Ventilated Patients -12- Day Shift Evening Shift Night shift Are standing order for drug administration available in each 1 Yes 2.No (If yes, to be enclosed (ANNEXURE-VIII) Are protocols(procedural& emergency management) 1.Yes 2.No. Available in each? (If yes, to be enclosed (ANNEXURE-IX) Equipments available in each icu(medical, Surgical Cardiac/Cardiothoracic,, Emergency Unit and other s) List of existing equipments in each should be attached in Annexure -X VI. A.Clinical Experience: Clinical Rotation Is rotation based on the need of clinical learning experiences 1.Yes 2.No. Stipulated by INC? If yes, Rotation plan to be enclosed. I Year (Annexure-XI ) II Year (Annexure-XII) Planning of Specific Clinical Experience Who prepares the Clinical Rotation and Clinical experience plan? 1.Faculty : 2.Hospitals Staff : Charge Nurse : Preceptor : (Medical /Nursing) 3.Faculty and Hospital staff (Change Nurse+ preceptor)

-13- B.Clinical Experience plan for each CCU Shows: i) Learning objectives 1.Yes 2.No ii) Learning Experiences 1.Yes 2.No iii)method of evaluation of learning experiences 1.Yes 2.No c.are the plans discussed with the students? 1.Yes 2.No d.)does clinical teaching take place? 1.Yes 2.No N.B: Inspectors to make observation of plan of different Clinical Experiences VII.TEACHING PLAN 1.Is the INC syllabus followed? 1.Yes 2.No 2. Is master plan for theory class and practical available? 1.Yes 2.No 3.Are broad guidelines for theory and clinical teaching available? 1.Yes 2.No 4.Is week/monthly time table for theory classes and 1.Yes 2.No Clinical teaching available in each CCU? VIII. SYSTEM OF EXAMINATION 1. Eligibility For Admission To Examination I)Attendance percentage :Theory classes Clinical practice ii)clinical Performance evaluation 1.Yes No iii) Are Internal assessment guidelines by INC followed? 1.Yes No If Yes, to be enclosed(annexure-xiii) 2. Is the place of exam same where students have been trained Yes /No (If No specify) 3.Who conducts the examination? Nursing Faculty 4. Internal Assessment (Practical): How many students are examined per day? Practical If no specify (Max- 5 students per day) 5.State the pattern of supplementary exam for(once/twice/per year) a. Theory b. Practical 6.Weak points on examination 7.Strong points on examination

-14- IX RECORDS OF STUDENT A.)Are the following student s records available and maintained well? a. Admission record 1.Yes 2.No. b.)daily attendance register 1.Yes 2.No c. Health record 1.Yes 2.No d. Clinical and Field experience record 1.Yes 2.No e. Practical record books-log book 1.Yes 2.No f. Leave record 1.Yes 2.No g. Cumulative record of each student 1.Yes 2.No B. Are the following records of the college and hospital maintained well? a. course planning of each subject 1.Yes 2.No b. Rotation Plans 1.Yes 2.No c.committee Meetings(Research)/Ethics Committee) 1 Yes 2 No d. Affiliation records, if any 1.Yes 2.No e. Records of Stock(Inventory of skill lab equipment) 1.Yes 2.No f.annual Report of activities and achievements 1.Yes 2 No g. Staff development programmers(for NPCC Program faculty) 1.Yes 2.No h. Records signed by Teacher with dates 1.Yes 2.No Verify Physically A& B) ENCLOSE SEPARATELY (Annexure-XIV ) What are the comments about this program by the Medical Superintendent/Hospital Director? X WELFARE ACTIVITIES A.STUDENT: 1.Professional Association / Activities TNAI No:.. 2. Health services are provided when students are sick : Yes No If yes name of the hospital Address : Pin : Tel : fax Email : Web site :

-15- a). Do students have Health Insurance : Yes No If yes, is the Health Insurance : Group Individual b) Name of the Health Insurance Company : Address : : : Pin : Tel : fax : Email : Web site : 3.Counselling Guidance : Available/ Not available 4.Eligible leave for students (*should adhere to INC norms) : 1. As per INC : 2. As per University : If not Remarks : 5.Is the Alumni Association for Graduates available : Yes / No B] FACULTY 1. Is there any Professional Organization for Faculty? : Yes No : If yes, name the Organization S.No 1. 2. 3. 4. 2.Is there any Faculty Committee, : Yes If yes, Name of the Committees S.No 1. 2. 3. 4. NAME OF THE ORGANIZATION No NAME OF THE COMMITTEES 3. Any other welfare activities S.No 1. 2. 3. 4. ACTIVITIES

-16-4. Eligible leave for faculty S.No NATURE OF LEAVE NO.OF.DAYS / year As per norms (Days) No. of days given by the institution 1. Casual leave 12 2. Sick/medical leave 10 3. Vacation/annual leave 30 4. Public holidays All govt.gazette holidays 5. Maternity leave As per policy of institution 6. On duty 15 5.Provides health services for the faculty when sick : Yes No If yes, name the Hospital Address : : Tel : Email : Web site : a)will the faculty have Health Insurance : Yes No If yes, is the Health Insurance : Group Individual b) Name of the Health Insurance Company Address : Pin : Tel : Fax : Email : Web site : 6. Are the faculty eligible for Provident Fund : Yes No 7.No. of faculty meeting conducted in a year :. 8.No.of Workshops/Seminar/Conference conducted by the Institution in a year :. 9.No. of faculty deputed for Conference/Workshop /Seminar in a year :

-17- Annexure - I Annexure II Annexure III Annexure IV ANNEXURES NABH Accreditation & JCI Nursing excellence Certificate Attested Copy of the Registered Trust/Society/ Missionary/Company Copy of Approval letter with sanctioned intake from Indian Nursing Council, New Delhi List of Critical care equipments and manikins to teach critical care skills Annexure V Last financial year s Audited Income and Expenditure Statement of the Institution Annexure VI Annexure VII Annexure VIII Annexure IX Annexure X Annexure XI Pollution control board certificate of the hospital List of Nurses with RN & RM Nos.(with renewal details) working in the Hospital Drug administration Protocols(procedural& emergency management) List of existing equipments in each Clinical Rotation Plan I Year Annexure XII Clinical Rotation Plan II Year Annexure XIII Annexure XIV Internal assessment guidelines by INC followed Comments about this program by the Medical Superintendent/Hospital Director