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Interoperability in Nursing.
Implementation of ICNP® in Poland.
Dorota Kilańska RN, MSc, PhD
EHealth Council in Nursing at the Center for Health Information Systems MoH
ICN-Accredited Centre For ICNP® Research & Development at the Medical University of Łódź
Iwona Szymańska RN, MSc, Medical University of Lodz
[email protected]
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of Łódź
D. Kilańska
Plan of the lecture
1) Recommendations for implementation of ICNP®
2) Application of the ICNP in the EHR in Poland
3) Use of the ICNP for knowledge management and
patient safety (results of care).
D. Kilańska
Background ICNP(R) development and dissemination in Poland
1989 – Resolution of ICN , Seul , South Korea;
1991 –1999 research - analysis of literature, questionnaire, the first draft of the list of terms, version α, β
version and then β2 (PNA involvement in the work in 1999);
2000 - Conference Translators and Reviewers ICNP®, sponsored by the "Tele Nurse“ & ICN Combra,
Portugal;
2005 – Version 1.0 – 1st Polish version;
2008 – Version 1.1
2009 – Version 2.0, PNA Recommendation & Policy Statement;
2011 –
Statement MoH/ICN/PNA, support letter of Minister of Administration and Digitization,
Statements of Main Chamber Nurses and Midwives (NRPiP),
2012 - Polish Version of ICNP ® 2011 (November),
2013 – Melbourne Version 4.,
Recommendation of Ehealth Council in Nursing, CSIOZ - NMDS in Poland,
2015 – Version 4 – Completed of Polish translation,
2006 - 2014 POLAND– 415 activities, lobbying , dissemination, teaching process, researches, & pilot
projects.
Version 2011,
D. Kilańska
„Elektroniczna
Platforma Electronic Platform for Gromadzenia,
Analizy
Collection, Analysis and i U
dostępniania
zasobów Dissemination of digital cyfrowych o Zdarzeniach resources for Medical Events Medycznych
(P1)” ‐
(P1) –
recommendations
rekomendacje
Recommendations
STRATEGIA WHO European EUROPEJSKIEGO Strategy KSZTAŁCENIA for Nursing and PIELĘGNIAREK WHO 2000
Midwifery Education, WHO 2000
2004 r. standard ISO FIDS
18104:2003 (Integration of
a Reference Terminology
Model for Nursing) ‐
Komitet Techniczny ISO
nr 215 – 3 grupa robocza
Międzynarodowego
(pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską
Stowarzyszenia
Informatyki
Medycznej
oraz
http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=33309
D. Kilańska
.
ICN
„Elektroniczna
Platforma Electronic Platform for Collection, Analysis and Gromadzenia,
Analizy i U
Dissemination of digital dostępniania zasobów resources for Medical Events cyfrowych o Zdarzeniach (P1) –
recommendations
Medycznych
(P1)” ‐
rekomendacje
The position of national consultants in the areas of:
Oncology Nursing
Nursing of the Chronically Ill and Disabled
Family Nursing
Paediatric Nursing
Palliative Care Nursing
Psychiatric Nursing
regarding the application of the ICNP ® classification in clinical Recommendations
WHO accepted ICNP STRATEGIA WHO European within the WHO‐FIC to EUROPEJSKIEGO Strategy extend coverage of the KSZTAŁCENIA domain of nursing for Nursing and PIELĘGNIAREK practice as an essential WHO 2000
Midwifery and complementary Education, WHO part of professional 2000
health services
Mapping ICNP to SNOMED CT
I‐NMDS
ICNP Catalogues
HOBIC
Dir 24/2011/UE
• eHealth
• Integrated
Care ‐
EUNRs4CARE
2004 r. standard ISO FIDS
18104:2003 (Integration of
a Reference Terminology
Model for Nursing) ‐
Komitet Techniczny ISO
nr 215 – 3 grupa robocza
Międzynarodowego
(pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską
Stowarzyszenia
Informatyki
Medycznej
oraz
http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=33309
practice
D. Kilańska
.
ICN
The Provisions and Recommendations
- The Provisions of the International Council of Nurses( ICN), 22nd May 2005
http://www.icn.ch/images/stories/documents/news/press_releases/2005_PR_10_Release_of_ICNP_V1.pdf
& 20th May 2013
http://www.icn.ch/images/stories/documents/news/press_releases/2013_PR_10_ICNP.pdf.
- Statement of XV National Congress of Delegates of
Polish Nurses Association, November
2009 http://www.ptp.na1.pl/pliki/PTP_Stanowiska/06_PTP_STAN_01_12_2009.pdf.
- Statement of Main Chamber Nurses and Midwives, June 2011,
https://docs.google.com/folder/d/0B4uc8m-
ugQHFNzhmbUkycC1YZjg/edit?docId=0B4uc8m-ugQHFVGxqVTBWQTNBXzg.
- Statement of National Congress of Delegates NIPiP, December 2011
http://www.izbapiel.org.pl/upload/Stanowisko%20Nr%204.pdf .
- Communique of MoH, ICN & PNA, 3rd July 2012
http://www.mz.gov.pl/wwwmz/index?mr=m7&ms=&ml=pl&mi=94&mx=0&mt=&my=0&ma=030372.
- EFN Policy Statement Continuity of Care & EFN Policy Statement of Nursing Sensitive Criteria
for the Selection of ‘European Centres of Excellence’ https://docs.google.com/folder/d/0B4uc8mugQHFNzhmbUkycC1YZjg/edit?docId=0B4uc8m-ugQHFcURHcVZpM3AwNHM.
- The WHO Family of International Classifications http://www.who.int/classifications/icd/adaptations/icnp/en/
The activities of the Polish Nurses Association in implementation eHealth services in nursing
https://docs.google.com/folder/d/0B4uc8m-ugQHFNzhmbUkycC1YZjg/edit?docId=0B4uc8m-ugQHFR3BiQWd0YllqZlE.
D. Kilańska
The Council of Ministers Directive, dated 12 April 2012, regarding the National
Interoperability Framework, the minimal requirements for public records and the exchange of
information in electronic form, as well as the minimum requirements for ICT systems
INTEROPERABILITY is achieved by:
1. Unification, understood as the application of compatible norms, standards
and procedures by the various entities performing public tasks.
2. Interchangeability, understood as the possibility of replacing the product,
process or service without simultaneous disruption of information
exchange between providers of public tasks or between them and their
customers, while meeting all functional requirements of cooperating
systems.
3. Compatibility, defined as the suitability of the products, processes or
services intended for common use, under specific conditions ensuring
provision of essential requirements and the absence of adverse effects
(...).
D. Kilańska
REGULATION OF THE MINISTER OF THE INTERIOR AND
ADMINISTRATION
dated 25 October 2007
regarding the type and range of medical documentation, as well as
the method of its processing in health care centres created by the
Minister for the Interior
§ 5. 1.
6) Information of the state of health and illness, as well as the Nursing
Process , diagnosis and treatment or care, including in particular:
a) a description of the actions performed by the doctor and nurse
b) diagnosis of the health problem, illness or injury
§ 11. 1. The history of the illness comprises: (…)
2) c. Individual nursing care card;
§ 14. 1. 3. Entries concerning the nursing process are made on a regular
basis by the nurse or midwife responsible for the care of the patient, and
are checked by the ward manager or senior midwife.
D. Kilańska
REGULATION OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION
regarding the type and range of medical documentation, as well as the
method of its processing in health care centres created by the Minister for the
Interior
3. The hospital treatment information card comprises: (…)
4 . Recommendations for further treatment, nutrition, nursing and lifestyle;
(…)
5. The section on health and illness associated with of Community Care
comprises:
6. Date of commencement and completion of nursing or midwifery care;
7. Type and range of nursing or midwifery activities including the patient and
environment, and in particular a recognition of the nursing and
psychosocial problems, a care plan of nursing or midwifery actions,
together with annotations connected with the performance of activities,
including those resulting from the instruction of the doctor; (…)
D. Kilańska
REGULATION OF THE MINISTER OF HEALTH
dated 21.12.2010 regarding the type and scope of medical
documentation, as well as the means of its storage 1)
3. Particular individual internal documents are as follows:
• health record;
•
medical history;
• newborn medical record;
• individual nursing care history; • individual midwifery care history;
• visit card;
• history of the environment and the family assesment.
3.1 To the individual internal documentation is attached a copy of the
documentation submitted by the patient, giving information needed for
diagnosis, treatment or nursing care.
1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i
zakresu dokumentacji medycznej oraz sposobu jej przetwarzania
D. Kilańska
REGULATION OF THE MINISTER OF HEALTH
dated 21.12.2010 regarding the type and scope of medical
documentation, as well as the means of its storage 1)
§ 10. Individual records, if the provisions of
the Regulation does not provide
otherwise, includes: (…)
3) designation of the person providing health
benefits and directing for examination,
consultation or treatment :
•
•
•
•
•
5) information on health and disease and the
diagnostic process, therapeutic, nursing
care or rehabilitation, in particular :
• description provided health benefits,
•
(…),
•
recommendations for patient, (…)
surname and name,
job title,
obtained specializations
number of the profession - in the case of a doctor, nurse and
midwife,
signature;
4) Date;
1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i
zakresu dokumentacji medycznej oraz sposobu jej przetwarzania
D. Kilańska
DIRECTIVE OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION
regarding the type and range of medical documentation, as well as the method of its processing in health care centres created by the Minister for the Interior
DIRECTIVE OF THE MINISTER OF HEALTH dated 21.12.2010 regarding the type and scope of medical documentation, as well as the means of its storage Nursing Process – ICN 2005
Terminology of reference – ICNP®
1) Warszawa, dnia 7 lutego 2014 r. Poz.177 OBWIESZCZENIE MINISTRA ZDROWIA z dnia 6 czerwca 2013 r. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie rodzajów i zakresu dokumentacji medycznej oraz sposobu jej przetwarzania
D. Kilańska
Projects
P1 ‐ P6
D. Kilańska
STRATEGIA EUROPEJSKIEGO KSZTAŁCENIA PIELĘGNIAREK WHO 2000
Platform for the Collection, Analysis and Dissemination of digital
resources concerning Medical Events
P1.1 "Approach to classifying medical documentation",
3.6 THE USE OF EXISTING TERMINOLOGY of REFERENCE
3.6.1 Dictionaries
Table 6. A list of proposed Terminology of Reference
lp.
The area of terminology
Recomended of Classifications
1.
Medications
Registry P1 drugs, ATC (Anatomical Therapeutic Chemical Classification System)
2.
Social and economic data
Dictionary of MPiPS; OECD, Social Indicators UNSTATS
3.
Recognision
ICD (…) ICNP
Treatment
(…)
ICNP – used in the actions, the outcomes obtained in nursing care in Nursing
(CSIOZ 2013: 29)
4.
D. Kilańska
Platform for the Collection, Analysis and Dissemination of
digital resources concerning Medical Events (P1)
Attachment no.3 for P1.1 "Approach to classifying medical documentation",
category "nursing documentation" - documents:
• History of the Individual nursing care 05.20
• History of the Individual midwifery care 05.21
• History of Patient 05.22
• Nursing recommendations 05.26
• Fluid balance 05.23
• BP and/or pulse measurements 05.24
• Nurse assessment card 05.25
• History of the Individual care in the family settings PHC 05.28
• Other nursing documentation 05.70 ????
D. Kilańska
E-DOCUMENTATION Nursing - PROJECT
Council Ehealth in nursing (przewodnicząca – dr Dorota
Kilańska)
przy CSIOZ - Center for Health Information Systems –
Units:
ELECTRONIC PATIENT RECORDS
Unit
(working on: schema of documentation, setting the
type of documents included in the nursing
documentation and the creation of this document for
different areas of nursing)
ICNP® Team
(working on Standards of Nursing Care Plans,
using of ICNP® Catalogues)
D. Kilańska
Recommendation of The Council for Ehealth in
Nursing, CSIOZ MoH, dated September 11, 2013 Proposed format of Nursing documentation
D. Kilańska
Council Recommendation of e-Health in Nursing at
CSIOZ in MZ
Recommendation no. 1/2013 dated 11 September 2013.
The Council for e-health in Nursing and the ICN-Accredited Centre for ICNP® Research & Development at the Medical
University of Łódź
regarding the design of electronic forms of medical documentation in Nursing The Council for e-health in Nursing recommends an
introduction to the "Individual Nursing Care Card", indicated in the Directive dated 21 December 2010 regarding the type
and scope of medical documentation, as well as the means of its storage § 2, provision. 3, point. 4. the following document
templates, being an integral part of the cards mentioned above:
1. Nursing interview card;
2. A patient evaluation card, together with a scaled evaluation of patient health, recommended by the International
Classification for Nursing Practice (ICNP), which can be found in the attachment to the recommendations below;
3. A plan of care based on the International Classification for Nursing Practice (ICNP ®), including the nurse's diagnosis
and actions/interventions, as well as outcome described based on the ICNP ® Classification;
4. Discharge card with instructions for the patient;
5. Nurse's Report;
6. Documents referred to in point. 1) to the point. 5) are the attachments from No. 1 to No. 5 to this Recommendation.
It is recommended for creating the architecture of nursing documentation based on the terminology of the International
Classification for Nursing Practice (ICNP ®).
D. Kilańska
Catalogue ICNP ®
International Classification for Nursing Practice (ICNP®)
D. Kilańska
MATERIALS for TEACHERS
ICNP Classification , PL version
Axis:
1. "diagnoza aktualna negatywna" - DC_negatywna_ICNP_2013.pdf (568 KB)
2. "diagnoza pozytywna" - DC_pozytywna_ICNP_2013_www.pdf (593 KB)
"OSIE PODSTAWOWE"
1. "Działania" (A)
"Interwencje"
(I)
2. "Lokalizacja"
(L)
3. "Czas"
(T)
4. "Klient"
(C)
5. "Środki"
(M)
6. "Osąd"
(J)
7. „Przedmiot opieki”
(F) – przeglądarka ICN http://icnp.stemos.com/index.php/pl/2013/
D. Kilańska
ICNP topics were discussed
Lectures
Practical lessons
Nursing Practice
Seminars
Others
# students
Bachelor level:
Lectures ‐ 16 294
Practical lessons ‐
5014
Nursing practice –
1785
ICNP® in Curricula
Bachelor
Bachelor &
MSc
Not performed
Others
Results
MoH/ACBiR/PNA 11.10.2014 Questionnaire was sent to 74 schools of nursing
Response – 23 Professional
training
Basic Nursing
Health Promotion
PHC
Internal Nursing
Surgical Nursing
# students of Master Degree – 9907
Lectures ‐ 8337, workshops (Łódź, Bydgoszcz)
# Case Studies with using of ICNP ‐
1290 (Nysa, Gdańsk, Lublin, Łódź)
Pediatric Nursing
Psychiatric Nursing
Informatics
Other nursing subjects
Others
status 25.10.2014
D. Kilańska
21 lectures (ICN‐
ACR&D, PNA) 3530 Participants
Postgraduate
training
55 trainings &
1590 Participants (2009, from December 2012 to November 2014) 2014 – 395 nurses & midwives
D. Kilańska
1. Białystok
2. Bydgoszcz
3. Ciechanów
4. Częstochowa
5. Gdańsk
6. Gorzów Wlkp.
7. Jachranka
8. Kalisz
9. Katowice
10. Kielce
11. Kraków
12. Krosno
13. Łódź
14. Nowy Sącz
15. Opole
16. Płock
17. Poznań
18. Radom
19. Rawa Mazowiecka
20. Rzeszów
21. Szczecin
22. Warszawa
23. Włocławek
24. Wrocław
25. Zielona Góra
status 25.10.2014
24.11.2009 – Paper CF/DSOZ/HKL/2009/076/0797
/W/21897 for the consideration of the introduction to reporting by the NHF health care benefits under the procedures with using ICNP ®
10.3. 2010 – National Health Found (NFZ) buisness meeting
Nurses & Midwives
Department MoH
11.12.2007 ‐ meeting of the National Consultants –
PNA lecture
2009 – replay to the
statements XV KZD (NFZ, Departament Zdrowia Publicznego, KRASZM, CKPPiP)
HEALTH POLICY
BUSINESS PARTNERS – the
agreement
PNA/KAMSOFT Company 2013/14 –
consultations
42 pisma w sprawie (2006‐2014)
Minister of Administration and Digitization
5.1.2012 ‐ to apply to the Ministry of Health to consider buying a Classification for EHR in
Poland
D. Kilańska
CSIOZ MoH
2010 – ICNP Council (39 meetings)
2012 – Ehealth Council in Nursing (17 meetings)
2013 – SNOMED –CT meeting
MoH
‐2011 Statement
ICN/PNA/MoH Communigue
on the MoH website, 3 July
2012. „Significant contribution to the International Classification for Nursing Practice (ICNP) in the interoperability of data in health care”
10.4.2015
translations
evaluation
translations
version2.0 – 55 meetings
wersji 1.0 (1.8.2006) 19 meetings (PTP ZG: Warszawa, Gdańsk, Łódź)
(telekonferencje september 2010 – august 2012, PTP ZG)
Translation of
ICNP
CSIOZ:
2012 ‐ agreement for translation of brochures
2013 – draft agreement with the ICN on the availability of the ICNP Evaluation translations
3.0 (ACBiR) ‐ The agreement with ICN in
February 2014
‐TELENRSCARE Project (April‐June
2014) ‐ 2 meetings
‐ Ehealth Council CSIOZ ‐ 4 meetings
10.4.2015
D. Kilańska
Business Partners
EHR – 2017 ?
•different functionality,
•diversity of projects, partners
•lack of cooperation
•inability to implement good practices
•the absence of clear indications in legal documents
The computerisation
of health protection
stan 25.10.2014 r.
D. Kilańska
Translation
D. Kilańska
The results of evaluation of the implementation
of the ICNP® in clinical practice
Group - nurses and midwives participating in ICNP®
workshops
N= 262
1 = definitely not
2 = not
3 = no opinion
4 = yes
5 = definitely yes
D. Kilańska
Survey N=262
1.Do you see a need for a standardized classification of
nursing practice according to ICNP® in Poland?
Mean response = 3.97
3. Are you sufficiently prepared to work with the computer
in order to implement an electronic nursing
documentation system? Mean response= 3.55
2.Will the introduction of the ICNP® be possible in
your workplace?
Mean response= 3.009
4. Are you ready to work with ICNP® in your practice?
Mean response = 3.13
D. Kilańska
European Federation of Nurses Associations The Nurses’ Voice
A Thematic Network to develop Evidence Based Guidelines for Nursing and Social Care on eHealth Services
www.ens4care.eu The objective
The main objective of the project is the development of
evidence based guidelines for the implementation of
eHealth services in nursing and social care, building on
existing good practices amongst the participants of the
Network, sharing and transferring knowledge across the
European Economic Area. The ultimate goal of
ENS4Care is the establishment of a sustainable
mechanism to support nursing and social care
research in the field of ICT enabled integrated care.
30
Requirements to implement the guideline
Stakeholders are recommended to use reference
terminology models (such as ICD, ICF, ICNP, ICPC,
SNOMED‐CT), which interpret in the same way the
diagnosis, interventions and outcomes.
The WHO HIS Strategic Planning Process Guidance
should also be considered, and in DRG can include all
Care Providers Services (WHO, 2009).
Every new device could be assessed by a national
Agency, which can be responsible for the evaluation
process on all devices needed by individuals and care
providers in health care.
31
ENS4Care General Assembly Dublin, 22 October 2014
ICNP ® PROJECT PARTNERS
Akredytowane Centrum badania i Rozwoju ICNP ® przy UM w Łodzi
D. Kilańska
"The student asks the master:
must one wait long for changes for the better?
The master answers:
if you want it, EXPECT TO WAIT LONG..."
D. Kilańska
Thank you for your attention
Dorota Kilańska
ICNP® Programme

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