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The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Interoperability in Nursing. Implementation of ICNP® in Poland.
Dorota Kilańska RN, MSc, PhDEHealth 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
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Plan of the lecture
1) Recommendations for implementation of ICNP®2) Application of the ICNP in the EHR in Poland3) Use of the ICNP for knowledge management and
patient safety (results of care).
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
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 – Version 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.
Background ICNP(R) development and dissemination in Poland
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
STRATEGIA EUROPEJSKIEGO
KSZTAŁCENIA PIELĘGNIAREK
WHO 2000
„Elektroniczna Platforma Gromadzenia, Analizy i U
dostępniania zasobów cyfrowych o Zdarzeniach
Medycznych (P1)” -rekomendacje
2004 r. standard ISO FIDS18104:2003 (Integration ofa Reference TerminologyModel for Nursing) - Komitet Techniczny ISO
nr 215 – 3 grupa robocza (pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską
Międzynarodowego Stowarzyszenia Informatyki Medycznej oraz ICN.http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=33309
WHO European Strategy
for Nursing and Midwifery
Education, WHO 2000
RecommendationsElectronic Platform for
Collection, Analysis and Dissemination of digital
resources for Medical Events (P1) – recommendations
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
STRATEGIA EUROPEJSKIEGO
KSZTAŁCENIA PIELĘGNIAREK
WHO 2000
„Elektroniczna Platforma Gromadzenia, Analizy i U
dostępniania zasobów cyfrowych o Zdarzeniach
Medycznych (P1)” -rekomendacje
2004 r. standard ISO FIDS18104:2003 (Integration ofa Reference TerminologyModel for Nursing) - Komitet Techniczny ISO
nr 215 – 3 grupa robocza (pojęcia zdrowotne) we współpracy z Grupą Pielęgniarską
Międzynarodowego Stowarzyszenia Informatyki Medycznej oraz ICN.http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=33309
WHO European Strategy
for Nursing and Midwifery
Education, WHO 2000
WHO accepted ICNP within the WHO-FIC to extend coverage of the
domain of nursing practice as an essential
and complementary part of professional
health services
Mapping ICNP to SNOMED CT
I-NMDSICNP Catalogues
HOBIC
Dir 24/2011/UE• eHealth• Integrated
Care -EUNRs4CAREThe position of national
consultants in the areas of:Oncology Nursing
Nursing of the Chronically Ill and Disabled
Family NursingPaediatric Nursing
Palliative Care NursingPsychiatric Nursing
regarding the application of the ICNP ® classification in clinical
practice
RecommendationsElectronic Platform for
Collection, Analysis and Dissemination of digital
resources for Medical Events (P1) – recommendations
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
- 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, November2009 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/0B4uc8m-ugQHFNzhmbUkycC1YZjg/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 nursinghttps://docs.google.com/folder/d/0B4uc8m-ugQHFNzhmbUkycC1YZjg/edit?docId=0B4uc8m-ugQHFR3BiQWd0YllqZlE.
The Provisions and Recommendations
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. 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(...).
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
REGULATION OF THE MINISTER OF THE INTERIOR AND ADMINISTRATION
dated 25 October 2007regarding 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 nurseb) 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.
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
REGULATION OF THE MINISTER OF THE INTERIOR AND ADMINISTRATIONdated 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
Interior3. 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; (…)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. 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)
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
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.
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. 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)
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
§ 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 :
• surname and name,• job title,• obtained specializations• number of the profession - in the case of a doctor, nurse and
midwife,• signature;
4) Date;
5) information on health and disease and thediagnostic process, therapeutic, nursingcare or rehabilitation, in particular :
• description provided health benefits,• (…),
• recommendations for patient, (…)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
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
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
DIRECTIVE OF THE MINISTER OF THE INTERIOR AND ADMINISTRATIONdated 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
Nursing Process – ICN 2005
Terminology of reference – ICNP®
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
STRATEGIA EUROPEJSKIEGO
KSZTAŁCENIA PIELĘGNIAREK
WHO 2000ProjectsP1 - P6
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
P1.1 "Approach to classifying medical documentation",3.6 THE USE OF EXISTING TERMINOLOGY of REFERENCE3.6.1 Dictionaries
Table 6. A list of proposed Terminology of Reference
Platform for the Collection, Analysis and Dissemination of digital resources concerning Medical Events
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
4. Treatment(…)ICNP – used in the actions, the outcomes obtained in nursing
care in Nursing (CSIOZ 2013: 29)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
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 ????
Platform for the Collection, Analysis and Dissemination of digital resources concerning Medical Events (P1)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
E-DOCUMENTATION Nursing - PROJECT
Council Ehealth in nursing (przewodnicząca – dr Dorota Kilańska)
przy CSIOZ - Center for Health Information Systems –Units:
ELECTRONIC PATIENT RECORDSUnit
(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)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Recommendation of The Council for Ehealth in Nursing, CSIOZ MoH, dated September 11, 2013 -
Proposed format of Nursing documentation
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. 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 Łódźregarding 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 ®).
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Catalogue ICNP ®International Classification for Nursing Practice (ICNP®)
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
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/
MATERIALS for TEACHERS
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Professional training
ResultsMoH/ACBiR/PNA 11.10.2014
Questionnaire was sent to 74 schools of nursing
Response – 23
# studentsBachelor level:
Lectures - 16 294Practical lessons -
5014Nursing practice –
1785
# students of Master Degree – 9907Lectures - 8337, workshops (Łódź, Bydgoszcz)# Case Studies with using of ICNP -1290 (Nysa, Gdańsk, Lublin, Łódź)
status 25.10.2014
ICNP topics were discussedLectures
Practical lessons
Nursing Practice
Seminars
Others
BachelorBachelor &
MSc
Not performed
Others
ICNP® in Curricula
Basic NursingHealth Promotion
PHCInternal Nursing
Surgical NursingPediatric Nursing
Psychiatric NursingInformatics
Other nursing subjects
Others
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
55 trainings &1590
Participants (2009, from December 2012 to
November 2014) 2014 – 395 nurses &
midwives
21 lectures (ICN-ACR&D, PNA)
3530 Participants
status 25.10.2014
1. Białystok2. Bydgoszcz3. Ciechanów4. Częstochowa5. Gdańsk6. Gorzów Wlkp.7. Jachranka8. Kalisz9. Katowice10. Kielce11. Kraków12. Krosno13. Łódź
14. Nowy Sącz15. Opole16. Płock17. Poznań18. Radom19. Rawa Mazowiecka20. Rzeszów21. Szczecin22. Warszawa23. Włocławek24. Wrocław25. Zielona Góra
Postgraduate training
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
HEALTH POLICY42 pisma w sprawie (2006-2014)
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
MoH-2011 StatementICN/PNA/MoH Communigueon the MoH website, 3 July2012. „Significant contribution to the International Classification for Nursing Practice (ICNP) in the interoperability of data in health care”
Nurses & MidwivesDepartment MoH
11.12.2007 - meeting of the National Consultants –PNA lecture2009 – replay to thestatements XV KZD (NFZ, Departament Zdrowia Publicznego, KRASZM, CKPPiP)
10.4.2015
CSIOZ MoH2010 – ICNP Council (39
meetings)2012 – Ehealth Council
in Nursing (17 meetings)
2013 – SNOMED –CT meeting
Minister of Administration and
Digitization5.1.2012 - to apply to the Ministry of Health to consider buying a Classification for EHR inPoland
BUSINESS PARTNERS – the
agreementPNA/KAMSOFT
Company 2013/14 –consultations
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
CSIOZ:2012 - agreement for translation of brochures2013 – draft agreement with the ICN on the availability of the ICNP
Translation of ICNP
evaluation translations
wersji 1.0 (1.8.2006)
19 meetings (PTP ZG: Warszawa, Gdańsk,
Łódź)
translationsversion2.0
– 55 meetings(telekonferencje september
2010 – august 2012, PTP ZG)
Evaluation translations3.0 (ACBiR)
- The agreement with ICN inFebruary 2014-TELENRSCARE Project (April-June2014) - 2 meetings- Ehealth Council CSIOZ - 4 meetings
10.4.2015
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
EHR – 2017 ?
Business Partners•different functionality,•diversity of projects, partners
•lack of cooperation•inability to implement good practices
•the absence of clear indications in legal documents
stan 25.10.2014 r.
The computerisation
of health protection
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Translation
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
The results of evaluation of the implementation of the ICNP® in clinical practice
Group - nurses and midwives participating in ICNP® workshops
N= 2621 = definitely not2 = not3 = no opinion4 = yes5 = definitely yes
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
Survey N=2621.Do you see a need for a standardized classification of nursing practice according to ICNP® in Poland?
Mean response = 3.972.Will the introduction of the ICNP® be possible inyour workplace? Mean response= 3.009
3. Are you sufficiently prepared to work with the computer in order to implement an electronic nursingdocumentation system? Mean response= 3.55
4. Are you ready to work with ICNP® in your practice?Mean response = 3.13
Euro
pean
Fed
erat
ion
of N
urse
s Ass
ocia
tions
Th
e N
urse
s’ V
oice
A Thematic Network to develop Evidence Based Guidelines for Nursing and Social Care on eHealth
Services
www.ens4care.eu
The objectiveThe main objective of the project is the development ofevidence based guidelines for the implementation ofeHealth services in nursing and social care, building onexisting good practices amongst the participants of theNetwork, sharing and transferring knowledge across theEuropean Economic Area. The ultimate goal ofENS4Care is the establishment of a sustainablemechanism to support nursing and social careresearch in the field of ICT enabled integrated care.
30
Requirements to implement the guidelineStakeholders are recommended to use referenceterminology models (such as ICD, ICF, ICNP, ICPC,SNOMED-CT), which interpret in the same way thediagnosis, interventions and outcomes.The WHO HIS Strategic Planning Process Guidanceshould also be considered, and in DRG can include allCare Providers Services (WHO, 2009).Every new device could be assessed by a nationalAgency, which can be responsible for the evaluationprocess on all devices needed by individuals and careproviders in health care.
31
ENS4Care General Assembly Dublin, 22 October 2014
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. Kilańska
ICNP ® PROJECT PARTNERS
Akredytowane Centrum badania i Rozwoju ICNP ® przy UM w Łodzi
The ICN-Accredited Centre for ICNP® Research & Development at the Medical University of ŁódźD. 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..."
Thank you for your attention
Dorota Kilańska
ICNP® Programme