Published on April 9, 2013
What is the AORN Syntegrity® Framework Standardized clinical content providing a consistent method for documenting perioperative patient care that has been validated by expert perioperative nurses Aligns documentation with nursing workflow enabling reliable and valid data to be captured Documentation represents the perioperative nursing plan of care via the most up-to-date version of the PNDS language (3rd version) Complement to a perioperative information system or Electronic Health Record
What is the AORN Syntegrity® Framework Standardized clinical content creates an information infrastructure for the aggregation of data to: − Report perioperative quality measures − Demonstrate compliance with practice standards, patient safety goals, and regulatory and accreditation criteria − Analyze operational efficiencies − Perform research The clinical content’s health record fields are derived from: – The Perioperative Nursing Data Set (PNDS) – AORN’s Perioperative Standards and Recommended Practices – Regulatory and accreditation requirements – Mandatory data for quality reporting
Founded on the PNDS Language 1993: Development of PNDS started 1999: Recognized by ANA 3rd version consists of – 50 Assessment interventions – 73 Implementation interventions – 25 Evaluation interventions • 148 Interventions total – 39 Outcomes – 156 NANDA Nursing Diagnosis Represents perioperative nursing plan of care
Fits Nursing Workflow (example)
Health Record Fields Mapped to PNDS (example) Associated assessment PNDS codes: A.20 Verifies operative procedure, surgical site and laterality. A.20.1 Verifies consent for planned procedure A.20.2 Assesses the risk for unintended retained foreign body Nursing Diagnosis Determined: Risk for Injury (00035)
Health Record Fields Mapped to PNDS (example) Documentation of counts represents the implementation of nursing care provided to prevent unintended retained foreign objects PNDS Implementation Code = Im.20 Performs required counts
Health Record Fields Mapped to PNDS (example) Documentation represents evaluation of the results of the counts and documentation of the outcome. PNDS Evaluation Code = E.50 Evaluates the results of the surgical count PNDS Outcome Code = O.20 Patient is free from unintended retainedO.20 Patient is free from unintended retained foreignobjects: foreign objects
Derived from Clinical Practice Standards Practices Standards – describe excellent nursing practice – Promote patient and health care worker safety – Guide policy and procedure development Clinical practice standards include those outside of AORN (ex. ANSI Laser Standards, AABB for blood transfusions) Yearly review of perioperative clinical practice standards Crosswalk of health record fields to standards for education and validation of documentation
Derived from Regulatory and Accreditation Criteria Yearly review of − Regulatory requirements (CMS) − Accreditation criteria (TJC, DNV, HFAP, AAAASF, etc) New accreditation agencies added as CMS approves Clinical content complies with elements of performance and requirements for surveys Crosswalk of health record fields to criteria for education and validation of documentation
Crosswalk to Standards and Regulations (example)
Derived from Mandatory Reporting CMS Quality Reporting: Inpatient, Outpatient, ASC Nurse Sensitive Measures: NQF, NDNQI , The Joint Commission Other Measures: AHRQ Patient Safety Indicators, Physician Quality Reporting Operational Reporting: process and workflow improvements
Mandatory Reporting (example) CMS Reporting: SCIP Measures Card-2 Surgery patients on beta-blocker therapy prior to arrival who received BB during the perioperative period INF-1 Prophylactic antibiotic received within one hour prior to incision INF-2 Prophylactic antibiotic selection INF-3 Prophylactic antibiotic discontinued 24 Hours after surgery end time INF-4 Cardiac surgery patients with controlled 6am postop blood glucose INF-9 Urinary catheter removed POD 1 or POD 2 with day of surgery as day zero INF-10 Surgery patients with perioperative temperature management AORN Measures: Operational Reporting Personnel Patient Times Procedure Specific Environmental
Mandatory Reporting (example) Nurse Sensitive Measure NQF Measures NQF-0515 Ambulatory surgery patients with appropriate hair removal NDNQI Perioperative Staffing Hours required for Magnet hospitals starting end of 2013 The Joint Commission Measures NSC-02 Pressure Ulcer Prevalence Other Measures AHRQ Patient Safety Indicators PSI-21 Rate of Foreign Body Left During Procedure Physician Quality Reporting System NQF-0454 Perioperative temperature management ACO Reporting ACO-17 Preventive Care & Screening; Tobacco Use: Screening and Cessation Intervention
Standardized Procedure List Over 1900 procedures Standardized naming convention Mapped to – SNOMED CT – CPT 4 – ICD-9 – ICD-10 Used by CMS for retooling of SCIP measures into eMeasures
Example of AORN Procedure List AORNAORN Name Synonym CPTs ICD9s SCT_IDsAmputation Arm Lower ArmLower Amputation 25905, 25900 84.05 400136002 33533, 33534, 36.14, 36.11, 33535, 33536, 36.13, 36.12, Coronary Artery 33510, 33511, 36.17, 36.10,Bypass Graft Bypass Graft 33512, 33513, 36.16, 36.19,Coronary Artery (CABG) 33514, 33517 36.15 232717009
Why the Framework
The Benefits of the Framework AORN Syntegrity® framework integrates a mix of standards, nursing process and outcome measures – Documentation aligned with health care standards – Documentation represents up-to-date perioperative nursing care planning – High quality, evidence-based clinical content at the point of care to support clinical decisions – Measures perioperative nursing contribution to patient care – Reliable and valid data for quality reporting – A tool to standardize documentation throughout an organization Standardization aids data collection, aggregation and benchmarking – Data collection that supports aggregation for quality reporting – Provides consistent and reliable data for formulation of organizational and public policy – Enhance ability to meet mandatory surgical reporting (SCIP, NQF) – Meet surgical regulatory compliance reducing the risk for citations
Value of the Framework Saves money. Reduces the amount of time clinical staff spends in the development, validation and management of perioperative documentation and keeps valuable clinical resources at the bedside providing direct patient care Accelerate the time-to-value. Unlock the value of the standardized nursing documentation as a foundation for reporting and benchmarking on performance improvement initiatives within the perioperative area Data-driven clinical decision making. Capitalize on the standardized data to perform more accurate analytics to improve performance, quality and efficiency while reducing cost
Value of the Framework Harmonization. AORN’s involvement in the development and ongoing review of standards related to perioperative nursing practice, patient safety, quality outcomes, health information technology and regulation enables harmonization of the clinical content with these standards Right strategic decision. Ensures the organization is producing valuable data from perioperative documentation that meets information and knowledge needs to improve the safety and quality of patient care Reduce care disparities, minimize errors, and save staff time. Potential to improve communication through consistent, clear documentation which enhances the continuity of patient care, minimizes errors and saves staff time
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CSC Proprietary and Confidential The AORN Syntegrity® Framework . HIMSS 2014
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