The AORN Syntegrity® Framework provides standardized clinical content and documentation that aligns with nursing workflow. It represents the perioperative nursing plan of care using the most updated Perioperative Nursing Data Set language. The framework was developed based on expert validation and incorporates standards, quality measures, and regulatory requirements to capture reliable data and ensure compliance. It allows for aggregation of data to report quality measures and analyze efficiencies while complementing existing information systems.

2. 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

3. 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

4. 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

5. Fits Nursing Workflow (example)

6. 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)

7. 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

8. 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 retained
O.20 Patient is free from unintended retained foreign
objects:
foreign objects

9. 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

10. 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

11. Crosswalk to Standards and
Regulations (example)

12. Agencies Reviewed

13. 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

14. 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

15. 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

16. 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

17. Example of AORN Procedure List
AORN
AORN Name Synonym CPTs ICD9s SCT_IDs
Amputation Arm Lower Arm
Lower 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

18. Why the Framework

19. 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

20. 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

21. 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

22. THANK YOU