The AORN Syntegrity Framework
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Transcript of The AORN Syntegrity Framework
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)
O.20 Patient is free from unintended retained foreign objects: retained
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 retained 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)
Agencies Reviewed
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 ReportingPersonnel
Patient Times
Procedure Specific
Environmental
Mandatory Reporting (example)
Nurse Sensitive MeasureNQF 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 MeasuresAHRQ 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
AORN NameAORN
Synonym CPTs ICD9s SCT_IDs
Amputation Arm Lower
Lower Arm Amputation 25905, 25900 84.05 400136002
Bypass Graft Coronary Artery
Coronary Artery Bypass Graft (CABG)
33533, 33534, 33535, 33536, 33510, 33511, 33512, 33513, 33514, 33517
36.14, 36.11, 36.13, 36.12, 36.17, 36.10, 36.16, 36.19, 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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