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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