Implementation Guide for the Nursing Management Minimum Data Set: NMMDS

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1 1 Implementation Guide for the Nursing Management Minimum Data Set: NMMDS Sponsored by: Center for Nursing Informatics School of Nursing University of Minnesota

2 2 Content INTRODUCTION... 3 Background... 3 Purpose... 4 Audience... 4 Contributors... 5 Scope... 6 Use Case Scenario... 6 SPECIFICATION OVERVIEW... 8 Organization of this Specification... 8 Convention used in this Implementation Guide... 9 Use of Vocabulary Standards NURSING MANAGEMENT MINIMUM DATA SET NMMDS Environment Nurse Resources COMPONENT - ENVIRONMENT Facility Unique Identifiers Type of Nursing Delivery Unit/Service Patient/Client Population Volume of Nursing Delivery Unit/Service Care Delivery Structure and Outcomes Patient/Client Accessibility Accreditation/Certification/Licensure COMPONENT - NURSE RESOURCES Staffing Satisfaction Nurse Demographics per Unit or Service Clinical Mental work Environmental Conditions Electronic Health Record (EHR) Implementation Stages REFERENCES APPENDIX A The Nursing Management Minimum Data Set Survey APPENDIX B - Publications - NMMDS Articles Published... 99

3 3 INTRODUCTION Background The Nursing Management Minimum Data Set (NMMDS) is a minimum collection of core variables needed by nurse managers to make decisions and compare nursing practice across institutions and geographical areas 1. The NMMDS is a profession-specific data set, developed through grounded theory, expert review panels, national Delphi surveys, focus groups, crosssectional descriptive surveys, and a national consensus working conference 2. It identifies common elements to represent nursing care delivery or the context of nursing care at the unit level or service line in any setting. The NMMDS provides managers and administrators standardized data that be compared within and across settings to understand how the context of care can influence patient and staff outcomes. These common elements can be measured to demonstrate the nursing component alone or as a part of broader care outcomes. Data elements reflect nursing practice and were selected to represent the essence of nursing. The context of care describes the overall setting or experience in which care takes place, such as home, acute care, long term care, and ambulatory or alternative care sites. The NMMDS Implementation Guide (IG) is a technical specification intended to guide the collection of data related to the context and support of direct health care delivery. NMMDS IG provides specifications regarding the precision in capturing, storing, and subsequently describing, analyzing, and comparing effects of patient care management and administrative interventions on complex health care outcomes. The NMMDS IG is based upon the NMMDS survey updates. It is a researchbased data set originally developed in 1989 to identify, define, and test the core variables needed to quantify at the unit or service line level within which health care is delivered 2. Initially, a focus group composed by nursing management and administration experts developed a list of management variables. After a pilot survey, a national Delphi survey was completed to determine necessity, clarity, and collectability of these variables within the acute care delivery system at the University of Iowa 2. The NMMDS research was extended, subsequently, to long term care, ambulatory care, home health care, and occupational health settings. The research included a partnership between The University of Iowa and the American Organization of Nurse Executives (AONE) in 1996 in order to disseminate and further refine those variables.

4 The NMMDS IG is expressed as a collection of data elements coded with the Logical Observation Identifiers Names and Codes (LOINC) standards. LOINC applies universal code names and identifiers to health terms related to laboratory and other clinical observations. Several standards organizations, such as Integrating the Healthcare Enterprise (IHE) or Health Level Seven (HL7), use LOINC to electronically transfer results from different reporting systems to the appropriate healthcare networks. A variety of information systems are involved when mapping the NMMDS variables using the LOINC codes. These include human resource systems, scheduling, acuity, and electronic health records. For instance, human resource systems include many of the variables about staffing Purpose The purpose of this NMMDS IG is to serve as a measure to nurses and health information technology (HIT) staff in implementing the collection of the data elements of the Nursing Management Minimum Data Set (NMMDS) in compliance with the LOINC terminology. The specification contains NMMDS elements with their specific LOINC mapping codes organized by sections according to the NMMDS hierarchy. Sections in the NMMDS IG contain NMMDS categories, data elements within the categories, conceptual and operational definition of each data element, recommendations for use where appropriate, and instructions about integration into information systems. These information systems may include electronic health records (EHRs), scheduling and / or human resource systems. Although the NMMDS has its own coding system, to support interoperability, the LOINC coding system should be integrated into electronic information systems. LOINC coding is provided in this document. Audience The primary audiences for this specification are nurse leaders, nurse informaticists, and HIT staff involved in implementing information systems and creating discrete measurement and analyses of the nursing component of health care. This audience will want to ensure that this specification adequately addresses the implementation of the NMMDS and their specific LOINC codes to support the national standards for interoperability. Secondary users of this specification include nurses working in any context of clinical practice, researchers and educators. This audience is responsible for adopting this guide into clinical practice, incorporating the data elements into research designs, and disseminating the 4

5 5 NMMDS IG to students and novice nurses for advanced learning and expertise. Researchers and educators are key experts in advancing and adopting this specification, to ensure that NMMDS information is consistent with the best nursing practices and nursing data exchange across settings. Contributors This specification was developed under the sponsorship of the Center for Nursing Informatics, School of Nursing, University of Minnesota under the leadership of Connie W. Delaney, PhD, RN, FAAN, FACMI who is one of the two original developers of the NMMDS (along with Diane Huber, PhD, RN, FAAN) and Co-director for the Center. Content expertise, project management, technical insights, and workflow knowledge was provided by Bonnie L. Westra, PhD, RN, FAAN, FACMI, Director for the Center for Nursing Informatics. Additional guidance was provided by Susan A. Matney, PhD, RN, FAAN, chair of the LOINC nursing subcommittee nursing special interest group. Description of the other contributors: Role Name Contact Author Connie Delaney Co-Author/Editor Initial Developers Bonnie L. Westra Lisiane Pruinelli Diane Huber Connie Delaney Project Manager Lisiane Pruinelli Project team members Jung In Park Colleen Hart Lynn Choromanski Mary Jo Swanson Tylor Wagner Amar Subramanian Dorcas Kunkel Mary Jo Swanson

6 6 Vocabulary Facilitator Susan Matney Project Sponsor Connie Delaney Subject Matter Expert Amy Garcia Subject Matter Expert Barbara Caspers Scope The scope of this specification is limited to implementing LOINC encoded NMMDS data. The specification is intended for use in the United States, but may be useful internationally. The NMMDS elements were mapped to LOINC database and encoded with LOINC identifiers. The associated answers are also mapped in the LOINC database and are encoded with LOINC Answer (LA) identifiers. The in-scope data elements are specified in the NMMDS update. The resultant March 2015 version of the NMMDS data elements, served as the foundation for the IG. Details for guiding the implementation and use of the NMMDS data includes environment and nurse resource categories. Financial elements, listed in Appendix A, are part of the NMMDS 2007 version, but to date have not been updated. Thus, the 2007 Financial category and data elements are out of the scope of this specification. The scope of this specification covers requirements that support standardized workforce nursing data. The specification complies with the National Database for Nursing Quality Indicators (NDNQI). This specification facilitates operation analysis, research and education. Use Case Scenario The Use Case covered by this specification is the integration of the NMMDS data elements into information systems and the extraction and use of the data for quality improvement, clinical operations improvement, NDNQI benchmarking or to meet Magnet Status recognition, and for research. Informaticians/ HIT staff use the NMMDS definitions and LOINC codes for coding data in information systems, extraction, and aggregation of the NMMDS data elements (see Fig. 1).

7 7 Informaticians code NMMDS data elements using the NMMDS definitions and LOINC codes. They also create data extracts or reports from the data. Nursing Managers and Administrators use aggregate data represented by NMMDS to: o Make decisions for nursing and the health system that improve the health of populations and clinical processes o Meet some NDNQI data reporting o Support data needed for Magnet Status Researchers use NMMDS data (alone or in combination with other data) to address research questions such as the influence of nursing models or staff variables on patient outcomes i.e. prevention of falls. Figure 1: Use Case for the integration of the NMMDS data elements into information system

8 8 SPECIFICATION OVERVIEW Organization of this Specification The data elements in this specification are grouped according to two high level categories: Environment and Nurse Resources. Each high level category contains NMMDS data elements with their associated number, name, definition, and specific LOINC mapping codes. Instructions about integration into information systems are included. The overall hierarchy of these data elements covered by this specification is illustrated in the flowchart below (Fig. 2). Figure 2: Hierarchy of the NMMDS data elements by high level categories

9 9 Convention used in this Implementation Guide This implementation guide follows formatting conventional. 1. The document is divided in Environment and Nurse Resources high level categories. 2. Each category has its own heading with its components. The original NMMDS code number is presented after each subheading in parenthesis. Heading and subheadings are in Bold. 3. Each component has one or more data elements. 4. Each data element has a code number expressing the original coding present in the data set and as the hierarchy inside the terminology. When the NMMDS was updated, some data elements were discontinued, others added. Therefore, numbers may not be sequential. 5. Each data element code is followed by its name. Some of these data elements have definitions, others not. When data elements have definitions, they are present after the name. 6. Each data element code and associated name is presented in Italics. 7. Each data element definition is in regular font formatting. 8. When there is a need to emphasize some context, the word or sentence is in Underlined. 9. Some data elements may use external resources, such as websites. When these resources are present, the hyperlink is present. 10. A data element may have specific types of coding that can be combined with other data elements coding. These specific types of coding are under a title with bottom and top borders, and in Bold. 11. Data elements may be require (R), optional (O) or conditional (C) 12. The LOINC code for each data element is listed after each data element description. 13. The LOINC concept codes and LOINC answers are listed in tables with the associated NMMDS specific code. 14. The type of answer for LOINC is listed in the last column for LOINC and labeled Ex. UCUM Units (Example Unified Code for Units of Measurement). 15. References for each element follow American Medical Association (AMA) guideline and are presented in the end of this implementation guide.

10 10 Use of Vocabulary Standards LOINC is a laboratory and clinical terminology system focused on observation information. LOINC was developed by Regenstrief Institute and the LOINC committee in 1994 and has historically focused on facilitating the exchange of laboratory information (chemistry, hematology, serology, microbiology, toxicology, cell counts, antibiotic susceptibilities, etc.). Subsequently, it was expanded to other clinical information class domains - vital signs, hemodynamics, intake/output, EKG, procedures, survey instruments, and other clinical observations and other assessments (Omaha System survey instruments, Patient Health Questionnaire set, HHS survey, MFS survey, etc.), management data (Nursing Management Minimum Data Set), and document types/attachments (ambulance reports, clinical reports, medication reports, laboratory reports, occupational therapy attachments, medical social work attachment, etc.). The LOINC standardized coding system was chosen to map and distribute the NMMDS because the question-answer format of LOINC matched the format for the NMMDS. That is, each NMMDS data element and sub-element is a question with different types of answers. For instance, one NMMDS data element (19.02) asks for the percent of nurses on a unit or for a service line by gender. The answers are the percent for females, males, or unknown. LOINC also provides an open source distribution of the LOINC coded NMMDS ( The LOINC coding for the NMMDS is available in this implementation guide, as well as on the LOINC website and through LOINC s downloadable software program called RELMA (Regenstrief LOINC Mapping Assistant).

11 11 NURSING MANAGEMENT MINIMUM DATA SET NMMDS The NMMDS document is a collection of data elements divided into two categories: Environment and Nurse Resources. Each of this category includes six unique data elements. Environment The environment is the community and life-style aspects of health that influence client and family need and resources, and their relationship to health care 3. The Environment category is composed of six data elements: Unit/Service Unique Identifier, Type of Nursing Delivery Unit/Service, Patient/Client Population, Volume of Nursing Structure and Outcomes, Patient/Client Accessibility, and Accreditation/Certification/Licensure. Nurse Resources The Nurse Resources category is at the leadership level (management/administration), where nurses in executive nursing practice identify commonalities, as well as differences, of personnel and conditions that are associated with care and care delivery. This category provides elements to measure the care and resource inputs within each setting and across two or more settings 3. Nurse Resources component has six data elements: Staffing, Satisfaction, Nurse Demographics per Unit or Service, Clinical Mental Work, Environmental Conditions, and Electronic Health Records (EHR) Implementation Stages.

12 12 COMPONENT - ENVIRONMENT 01 Facility Unique Identifiers A facility is the highest level of an organization for data aggregation for which unit level data are reported. In some cases, a facility is the same as a unit if there is only one unit Federal Provider Number Facility The National Provide Identifier (NPI) is a unique identification number for health care providers specified by HIPAA. For the NMMDS, the NPI for organizations will be used to indicate the place that sends the bill. (Heart association, Catholic Charities) Facility Name Legal name of the facility Geographic location State or Territory of the facility where the service was provided or originated as defined by the United States Postal Service ( Postal Location (zip code) zip code of the facility where service was provided or originated as defined by the United States Postal Service use a nine digit if possible ( Place of Service Place of service is the location, as indicated on health care professional claims forms, where the service was provided or originated. It is represented by two-digit codes as defined by Centers for Medicare & Medicaid Services (CMS). ( The NMMDS uses the CMS list plus additional codes that end with an x. 1X Stores these may include grocery, pharmacy, department or other stores where retail goods and merchandise are sold 2X Voluntary Health or Charitable Agencies - (e.g., National Cancer Society) Reporting period Starting through end date for the period of time in which LOINC Coding events occurred not when the data are collected or reported Start Date/Time End Date/Time

13 13 LOINC Code NMMDS Component Data Type NMMDS Code NMMDS panel Facility Answer List Facility unique identifier panel Panel Federal provider number Facility Enumerated (See Link) Federal provider name Facility Text State, district or territory federal Enumerated (See abbreviation Facility Link) ZIP code Facility Enumerated (See Link) Place of service Enumerated (See Link) Survey reporting period start date Date Facility Survey reporting period end date Facility Date Type of Nursing Delivery Unit/Service The unique name, identifier, and type of nursing unit or service for each component of the facility Unique Unit Cost Center An identifier given to a cost center by the facility for a unit which only has meaning within the facility; this is the first level of data aggregation beyond the individual patient or care provider Unique Unit Name The name assigned to a unit by the facility, which only has meaning within the facility Type of Nursing Delivery Unit or Service Select all categories that most accurately describe the unit type or specialty (This is the NDNQI List In Appendix D Adult Critical Care Unit Adult Burn Critical Care Unit Adult Cardiothoracic Critical Care Unit Adult Coronary Critical Care Unit Adult Medical Critical Care Unit Adult Neurology Critical Care Unit

14 Adult Pulmonary Critical Care Unit Adult Surgical Critical Care Unit Adult Trauma Critical Care Unit Adult Step-down Unit Adult Med-Surg Step-down Unit Adult Medical Step-down Unit Adult Surgical Step-down Unit Adult Medical Unit Adult Bone Marrow Transplant Medical Unit Adult Cardiac Medical Unit Adult Gastrointestinal Medical Unit Adult Infectious Disease Medical Unit Adult Neurology Medical Unit Adult Oncology Medical Unit Adult Renal Medical Unit Adult Respiratory Medical Unit Adult Surgical Unit Adult Bariatric Surgical Unit Adult Cardiothoracic Surgical Unit Adult Gynecology Surgical Unit Adult Neurosurgery Surgical Unit Adult Orthopedic Surgical Unit Adult Plastics Surgical Unit Adult Transplant Surgical Unit Adult Trauma Surgical Unit Adult Med-Surg Combination Unit Adult Cardiac Med-Surg Combination Unit Adult Neuro/Neurosurgery Med-Surg Combination Unit

15 Adult Oncology Med-Surg Combination Unit Adult Obstetrics Unit Adult Obstetrics Ante-Partum Unit Adult Obstetrics Labor & Delivery Unit Adult Obstetrics Mother/Baby Combined Unit Adult Obstetrics Post-Partum Unit Other Adult Skilled Nursing Unit Other Adult Mixed Acuity Unit Neonatal Level I Neonate-Continuing Care Unit Neonatal Level II Neonate-Intermediate Care Unit Neonatal Level III/IV Neonatal Critical Care Unit Neonatal Well Baby Nursery Unit Neonatal Mixed Acuity Unit Adult Rehabilitation Unit Adult Brain Injury/Spinal Cord Injury Rehabilitation Unit Adult Cardiopulmonary Rehabilitation Unit Adult Neurology/Stroke Rehabilitation Unit Adult Orthopedic/Amputee Rehabilitation Unit Pediatric Rehabilitation Unit Mixed Acuity Rehabilitation Unit Pediatric Critical Care Unit Pediatric Burn Critical Care Unit Pediatric Cardiothoracic Critical Care Unit Pediatric Coronary Critical Care Unit Pediatric Medical Critical Care Unit Pediatric Neurology Critical Care Unit Pediatric Pulmonary Critical Care Unit Pediatric Surgical Critical Care Unit

16 Pediatric Trauma Critical Care Unit Pediatric Step Down Unit Pediatric Med-Surg Step-down Unit Pediatric Medical Step-down Unit Pediatric Surgical Step-down Unit Pediatric Medical Unit Pediatric Bone Marrow Transplant Medical Unit Pediatric Cardiac Medical Unit Pediatric Gastrointestinal Medical Unit Pediatric Infectious Disease Medical Unit Pediatric Neurology Medical Unit Pediatric Oncology Medical Unit Pediatric Renal Medical Unit Pediatric Respiratory Medical Unit Pediatric Surgical Unit Pediatric Bariatric Surgical Unit Pediatric Cardiothoracic Surgical Unit Pediatric Gynecology Surgical Unit Pediatric Neurosurgery Surgical Unit Pediatric Orthopedic Surgical Unit Pediatric Plastics Surgical Unit Pediatric Transplant Surgical Unit Pediatric Trauma Surgical Unit Pediatric Med-Surg Combination Unit Pediatric Cardiac Med-Surg Combination Unit Pediatric Neurology/Neurosurgery Combination Unit Pediatric Oncology Med-Surg Combination Unit Pediatric Mixed Acuity Unit

17 Adult Psychiatric Inpatient Unit Adult General Psychiatric Inpatient Unit Adult Intensive Psychiatric Inpatient Unit Adult Mixed Acuity Psychiatric Inpatient Unit Adolescent Psychiatric Inpatient Unit Adolescent General Psychiatric Inpatient Unit Adolescent Intensive Psychiatric Inpatient Unit Adolescent Mixed Acuity Psychiatric Inpatient Unit Child Psychiatric Inpatient Unit Child General Psychiatric Inpatient Unit Child Intensive Psychiatric Inpatient Unit Child Mixed Acuity Psychiatric Inpatient Unit Child-Adolescent Psychiatric Inpatient Unit Child-Adolescent General Psychiatric Inpatient Unit Child-Adolescent Intensive Psychiatric Inpatient Unit Child-Adolescent Mixed Acuity Psychiatric Inpatient Unit Geripsych Inpatient Unit Geripsych General Psychiatric Inpatient Unit Geripsych Intensive Psychiatric Inpatient Unit Geripsych Mixed Acuity Psychiatric Inpatient Unit Behavioral Health Inpatient Unit Behavioral Health General Psychiatric Inpatient Unit Behavioral Health Intensive Psychiatric Inpatient Unit Behavioral Health Mixed Acuity Psychiatric Inpatient Unit Specialty Psychiatric Inpatient Unit Specialty Psychiatric General Inpatient Unit Specialty Psychiatric Intensive Inpatient Unit Specialty Psychiatric Mixed Acuity Inpatient Unit

18 Multiple Psychiatric Unit Types Inpatient Unit Multiple Psychiatric Unit Types General Inpatient Unit Multiple Psychiatric Unit Types Intensive Inpatient Unit Multiple Psychiatric Unit Types Mixed Acuity Inpatient Unit Other Psychiatric Inpatient or Outpatient Units Psychiatric Day Hospital Outpatient Psychiatric Clinics Psychiatric Residential Unit (no 24/7 nurse) Emergency Department General Emergency Department Obstetrics Emergency Department Pediatric Emergency Department Urgent Care Emergency Department Peri-operative Unit Post Anesthesia Care Unit Pre-Op Holding Operating Room Same Day/Ambulatory Surgery General Ambulatory Care Cardiac Rehabilitation Clinic Outpatient Clinics Outpatient Rehabilitation Clinic Radiation Therapy Clinic Wound Care Clinic Interventional Unit Bronchoscopy Unit Catheterization Lab Unit Dialysis Unit

19 Gastrointestinal Clinic Infusion Unit Pain Management Unit Radiology Unit Short Stay Unit Other Clinic ou Unit Home Health Clinic Hospice/Palliative Care Clinic Long Term Care Unit Patient Preparation/Education Clinic Work Group Clinic Public Health Clinic School Health Clinic Aerospace Clinic Continence Care Clinic Flight Clinic Genetics/Genetics Counseling Clinic Health Promotion Clinic Infection Control Clinic Nutrition Support Clinic Occupational Health Clinic Ophthalmic Clinic Ostomy Care Clinic Reproductive Endocrinology/Infertility Clinic Women's Health Care, Ambulatory Clinic

20 20 LOINC Coding LOINC Code NMMDS Component Data Type NMMDS Code NMMDS panel Facility Answer ID NMMDS Code NMMDS nursing delivery unit or service 02 panel Facility Nursing unit cost center Text Nursing unit name Text Type of nursing unit or service [NDNQI] LL LOINC Answer List Type of nursing unit or service [NDNQI] Answer Set these are the potential values for Type of nursing unit or service from NORMATIVE ANSWER LIST LL Data can be captured at the higher level which are NMMDS codes that are xx or at more granular level, which are codes that are xx.xx. Sequence # NMMDS Component Answer ID NMMDS Code 1 Adult Critical Care Unit LA Adult Burn Critical Care Unit LA Adult Cardiothoracic Critical Care Unit LA Adult Coronary Critical Care Unit LA Adult Medical Critical Care Unit LA Adult Neurology Critical Care Unit LA Adult Pulmonary Critical Care Unit LA Adult Surgical Critical Care Unit LA Adult Trauma Critical Care Unit LA Adult Step-down Unit LA Adult Med-Surg Step-down Unit LA Adult Medical Step-down Unit LA Adult Surgical Step-down Unit LA Adult Medical Unit LA Adult Bone Marrow Transplant Medical LA Unit 16 Adult Cardiac Medical Unit LA Adult Gastrointestinal Medical Unit LA Adult Infectious Disease Medical Unit LA Adult Neurology Medical Unit LA Adult Oncology Medical Unit LA Adult Renal Medical Unit LA Adult Respiratory Medical Unit LA Adult Surgical Unit LA Adult Bariatric Surgical Unit LA Adult Cardiothoracic Surgical Unit LA

21 21 26 Adult Gynecology Surgical Unit LA Adult Neurosurgery Surgical Unit LA Adult Orthopedic Surgical Unit LA Adult Plastics Surgical Unit LA Adult Transplant Surgical Unit LA Adult Trauma Surgical Unit LA Adult Med-Surg Combination Unit LA Adult Cardiac Med-Surg Combination LA Unit 34 Adult Neuro/Neurosurgery Med-Surg LA Combination Unit 35 Adult Oncology Med-Surg Combination LA Unit 36 Adult Obstetrics Unit LA Adult Obstetrics Ante-Partum Unit LA Adult Obstetrics Labor & Delivery Unit LA Adult Obstetrics Mother/Baby Combined LA Unit 40 Adult Obstetrics Post-Partum Unit LA Other Adult Skilled Nursing Unit LA Other Adult Mixed Acuity Unit LA Neonatal Level I Neonate-Continuing Care LA Unit 44 Neonatal Level II Neonate-Intermediate LA Care Unit 45 Neonatal Level III/IV Neonatal Critical LA Care Unit 46 Neonatal Well Baby Nursery Unit LA Neonatal Mixed Acuity Unit LA Adult Rehabilitation Unit LA Adult Brain Injury/Spinal Cord Injury LA Rehabilitation Unit 50 Adult Cardiopulmonary Rehabilitation LA Unit 51 Adult Neurology/Stroke Rehabilitation LA Unit 52 Adult Orthopedic/Amputee Rehabilitation LA Unit 53 Pediatric Rehabilitation Unit LA Mixed Acuity Rehabilitation Unit LA Pediatric Critical Care Unit LA Pediatric Burn Critical Care Unit LA Pediatric Cardiothoracic Critical Care LA Unit 58 Pediatric Coronary Critical Care Unit LA Pediatric Medical Critical Care Unit LA

22 22 60 Pediatric Neurology Critical Care Unit LA Pediatric Pulmonary Critical Care Unit LA Pediatric Surgical Critical Care Unit LA Pediatric Trauma Critical Care Unit LA Pediatric Step Down Unit LA Pediatric Med-Surg Step-down Unit LA Pediatric Medical Step-down Unit LA Pediatric Surgical Step-down Unit LA Pediatric Medical Unit LA Pediatric Bone Marrow Transplant LA Medical Unit 70 Pediatric Cardiac Medical Unit LA Pediatric Gastrointestinal Medical Unit LA Pediatric Infectious Disease Medical LA Unit 73 Pediatric Neurology Medical Unit LA Pediatric Oncology Medical Unit LA Pediatric Renal Medical Unit LA Pediatric Respiratory Medical Unit LA Pediatric Surgical Unit LA Pediatric Bariatric Surgical Unit LA Pediatric Cardiothoracic Surgical Unit LA Pediatric Gynecology Surgical Unit LA Pediatric Neurosurgery Surgical Unit LA Pediatric Orthopedic Surgical Unit LA Pediatric Plastics Surgical Unit LA Pediatric Transplant Surgical Unit LA Pediatric Trauma Surgical Unit LA Pediatric Med-Surg Combination Unit LA Pediatric Cardiac Med-Surg Combination LA Unit 88 Pediatric Neurology/Neurosurgery LA Combination Unit 89 Pediatric Oncology Med-Surg LA Combination Unit 90 Pediatric Mixed Acuity Unit LA Adult Psychiatric Inpatient Unit LA Adult General Psychiatric Inpatient Unit LA Adult Intensive Psychiatric Inpatient LA Unit 94 Adult Mixed Acuity Psychiatric Inpatient LA Unit 95 Adolescent Psychiatric Inpatient Unit LA Adolescent General Psychiatric Inpatient Unit LA

23 23 97 Adolescent Intensive Psychiatric Inpatient LA Unit 98 Adolescent Mixed Acuity Psychiatric LA Inpatient Unit 99 Child Psychiatric Inpatient Unit LA Child General Psychiatric Inpatient Unit LA Child Intensive Psychiatric Inpatient LA Unit 102 Child Mixed Acuity Psychiatric Inpatient LA Unit 103 Child-Adolescent Psychiatric Inpatient LA Unit 104 Child-Adolescent General Psychiatric LA Inpatient Unit 105 Child-Adolescent Intensive Psychiatric LA Inpatient Unit 106 Child-Adolescent Mixed Acuity LA Psychiatric Inpatient Unit 107 Geripsych Inpatient Unit LA Geripsych General Psychiatric Inpatient LA Unit 109 Geripsych Intensive Psychiatric Inpatient LA Unit 110 Geripsych Mixed Acuity Psychiatric LA Inpatient Unit 111 Behavioral Health Inpatient Unit LA Behavioral Health General Psychiatric LA Inpatient Unit 113 Behavioral Health Intensive Psychiatric LA Inpatient Unit 114 Behavioral Health Mixed Acuity LA Psychiatric Inpatient Unit 115 Specialty Psychiatric Inpatient Unit LA Specialty Psychiatric General Inpatient LA Unit 117 Specialty Psychiatric Intensive Inpatient LA Unit 118 Specialty Psychiatric Mixed Acuity LA Inpatient Unit 119 Multiple Psychiatric Unit Types Inpatient LA Unit 120 Multiple Psychiatric Unit Types General LA Inpatient Unit 121 Multiple Psychiatric Unit Types Intensive Inpatient Unit LA

24 Multiple Psychiatric Unit Types Mixed LA Acuity Inpatient Unit 123 Other Psychiatric Inpatient or Outpatient LA Units 124 Psychiatric Day Hospital LA Outpatient Psychiatric Clinics LA Psychiatric Residential Unit (no 24/7 LA nurse) 127 Emergency Department LA General Emergency Department LA Obstetrics Emergency Department LA Pediatric Emergency Department LA Urgent Care Emergency Department LA Peri-operative Unit LA Post Anesthesia Care Unit LA Pre-Op Holding LA Operating room LA Same Day/Ambulatory Surgery LA General Ambulatory Care LA Cardiac Rehabilitation Clinic LA Outpatient Clinics LA Outpatient Rehabilitation Clinic LA Radiation Therapy Clinic LA Wound Care Clinic LA Interventional Unit LA Bronchoscopy Unit LA Catheterization Lab Unit LA Dialysis unit LA Gastrointestinal Clinic LA Infusion Unit LA Pain Management Unit LA Radiology Unit LA Short Stay Unit LA Other Unit or Clinic LA Home Health Clinic LA Hospice/Palliative Care Unit LA Long Term Care Unit LA Patient Preparation/Education Clinic LA Work Group Clinic LA Public Health Clinic LA School Health Clinic LA Aerospace Clinic LA Continence Care Clinic LA Flight Clinic LA Genetics/Genetics Counseling Clinic LA

25 Health Promotion Clinic LA Infection Control Clinic LA Nutrition Support Clinic LA Occupational Health Clinic LA Ophthalmic Clinic LA Ostomy Care Clinic LA Reproductive Endocrinology/Infertility LA Clinic 171 Women's Health Care, Ambulatory Clinic LA Patient/Client Population Characteristics of the population served by nursing delivery unit or service. Identify all categories that best describe the actual patient/client population served by the nursing delivery unit/service Chronological age Percent of the population during the reporting period of the appropriate age served on the nursing delivery unit or service (this is a modification of age categories listed at Fetal days (neonatal) days - 1 year years years years years years years years years years years

26 years years years years years years years years Catchment Area This is an estimate of the percent of patients served by this nursing delivery unit or service by geographical area. Select the smallest geographical unit that best fits the population served Neighborhood City or Town District catchment area County catchment area Parish catchment area State catchment area Region catchment area Nation catchment area World catchment area Aerospace catchment area Nautical catchment area Total Patient Population a count of the patient population during the reporting LOINC Coding period. LOINC Code LOINC component Data Type NMMDS Code Patient/Client Population Population distribution panel (chronological age) % for each age group 03.02

27 Catchment area panel population % for each catchment group Total patient population # # LOINC Answer List Population distribution panel (chronological age) [NMMDS] use answers below Sequence # NMMDS Component Answer Type NMMDS Code Population distribution panel (chronological age) Total population of fetal age population % Total population of age birth to 28 days % population Total population of age 29 days to 1 year % population Total population of age 1-4 years population % Total population of age 5-9 years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age years population % Total population of age GE 85 years population % Catchment area panel population [NMMDS] use answers below Sequence# NMMDS Component Answer Type NMMDS Code Catchment area panel population Neighborhood catchment area population % [Estimated] City or town catchment area population % [Estimated] District catchment area population [Estimated] % County catchment area population [Estimated] % Parish catchment area population [Estimated] %

28 State catchment area population [Estimated] % Region catchment area population [Estimated] % Nation catchment area population [Estimated] % World catchment area population [Estimated] % Aerospace catchment area population % [Estimated] Nautical catchment area population [Estimated] % Volume of Nursing Delivery Unit/Service The number of nursing encounters with related hours for direct and indirect activities that can be associated with the provision of care to a client for a unit or service during a reporting period. The volume of nursing care is determined by combining a type of encounter with a type of nursing provider with a type of client and then either the designated number of hours per encounter, maximum number of encounters possible or actual number of encounters on a unit for a reporting period. An encounter is an interaction between a provider and a client for the direct provision of health care service(s) 4, Type of Nursing Provider - A designation for nursing personnel based on educational preparation, licensure, or certification Certified Advanced Practice Nurse (APN) Registered Nurse, not APN Licensed Practical/ Vocational Nurse (LPN/ LVN) Unlicensed Assistive Personnel (UAP) i.e. nursing assistant or home health aide Total nursing personnel that includes APN, registered nurse, LPN/ LVN, and UAP Type of Client Individual Client- An individual who can be uniquely identified 6,7 and is the recipient of health care or health related services Family - Two or more individuals affiliated by marriage, birth, adoption, biologic, legal ties, social relationships, significant or close other as identified by the patient or client as family 7-10.

29 Population A group of individuals living in a specific geographic area (e.g., a neighborhood, community, city, or county) or associated with a particular group (e.g. race, ethnicity, age) who experience or are at risk for common health related issues (e.g., exposures, health care resources, outcomes, etc.) Type of Encounter Patient Days - the patient census for a unit or service in a 24 hour period Method 1: Patient Days: Midnight Census The daily number should be summed for every day in the month 12(p1) Method 2: Patient Days: Midnight Census plus Actual Hours for Short Stay Patients - The short stay days should be reported separately from midnight census and will be summed by NDNQI to obtain patient days. The total daily hours for short stay patients should be summed for the month and divided by 24 12(p1) Method 3: Patient Days: Midnight Census plus Average Hours for Short Stay Patients - The short stay average is to be obtained from a special study documenting the time spent by short stay patients on specific unit types. Average short stay days should be reported separately and are added with midnight census to obtain patient days. The average daily hours should be multiplied by the number of days in the month and the product divided by 24 to produce average short stay days 12(p2) Method 4: Patient Days: Actual Hours - Sum actual hours for all patients, whether in-patient or short stay, and divide by 24 12(p2) Method 5: Patient Days from multiple Census Reports - A sum of the daily average censuses can be calculated to determine patient days for the month on the unit 12(p2) Visits - A provider-patient interaction either in person or via telehealth or other face-face technologies.

30 Consults An interaction with a client for whom the nurse is not the primary care provider and was requested to see the client for advice, share information, or exchange views Contacts - An interaction with a client that is not otherwise counted in other categories. Examples might be phone calls, mailing, ing or other methods of connecting with a patient Programs - A focal area of health for groups, communities or populations for which various activities can be associated. Typically this is used in public health such as for TB management and includes interventions such as program planning, management, and evaluation; case finding; education; advocacy; outreach; coalition building; etc. If an activity is included under program, do not include it under other categories such as classes Classes - Two or more patients with a common learning need for which knowledge, skills or attitudes are addressed Number of Hours Designated per Encounter - Estimate of direct and indirect hours of nursing care that are client related including nursing activities that occur away from the [client] (e.g., care coordination, documentation time, travel time, treatment planning) 14. This category does not include all paid hours when activities cannot be directly attributable to the care of a specific client (e.g., sick time, vacation, education leave or orientation) 14. Designated hours of nursing care include hours worked by employees or contract nursing staff, i.e., APN, RN, LPN/LVN, unlicensed assistive personnel (UAP) Encounter Capacity estimate of the number of encounters during a reporting period that could be provided for a unit or service. The estimate is derived from budgeted care on a unit or service for the reporting period Actual Encounters the actual number of encounters during the reporting period by type of encounter selected for a unit or service. LOINC Coding LOINC Code NMMDS Component Data Type NMMDS Code

31 Volume of nursing delivery unit or 04 service panel Type of nursing provider [NMMDS] LL Type of client [NMMDS] LL Type of encounter [NMMDS] LL Hours designated [Estimate] h Care capacity # [Estimate] {#} Care provided # {#} LOINC Answer List Type of nursing provider [NMMDS] - Normative answer list (LL767-5) Sequence # NMMDS Component Answer ID NMMDS Code 1 APN LA RN LA LPN/ LVN LA UAP LA Total nursing personnel LA Type of client [NMMDS] - Normative answer list (LL768-3) Sequence # NMMDS Component Answer ID NMMDS Code 1 Individual LA Family LA Population LA Type of encounter [NMMDS] - Normative answer list (LL769-1) Sequence # NMMDS Component Answer ID NMMDS Code 1 Patient days method 1 LA Patient days method 2 LA Patient days method 3 LA Patient days method 4 LA Patient days method 5 LA Visits LA Consults LA Contacts LA Programs LA Classes LA RECOMMENDED CODING

32 32 Coding includes combining NMMDS data element, type of nurse provider, type of client, type of encounter, and information about the encounter. NMMDS Data element Type of nursing provider Type of client Type of encounter Encounter Details APN 02 RN 03 LPN/ LVN 04 UAP 05 Total nursing personnel 01 Individual 02 Family 03 Population 01 Patient Days Method 1 02 Patient Days Method 2 03 Patient Days Method 3 04 Patient Days Method 4 05 Patient Days Method 5 06 Visits 07 Consults 08 Contacts 09 Programs 10 Classes 01 Hours/ encounter 02 Encounter Capacity 03 Actual Encounters RECOMMENDATIONS FOR EACH TYPE OF NURSE PROVIDER There are some combinations type of encounter and type of client that are not logical. The following are the recommended types of clients and encounter types for each type of nurse provider. For each combination, the reporting unit/ service would always report three numbers: hours/ encounter, encounter capacity, and actual encounters. Certified Advanced Practice Nurse (APN) Individual Family Population Patient Days Method 1 Patient Days Method 2 Patient Days Method 3 Patient Days Method 4 Patient Days Method 5 X X X X X Visits X X X Consults X X X Contacts X X X

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