Clinical Care Classification (CCC) System Seminar University of Eastern Finland. Kuopio Campus, Finland June 2, 2015
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1 Clinical Care Classification (CCC) System Seminar University of Eastern Finland Kuopio Campus, Finland June 2, 2015
2 Clinical Care Classification (CCC) System Virginia K. Saba, EdD, RN, FAAN, FACMI, LL President & CEO, SabaCare Inc. Adjunct Professor, Uniformed Services University (USU) Distinguished Scholar, Emeritus, Georgetown University -SNHS 2
3 Objectives Provide Nursing Informatics Background for CCC System Provide Clinical Nursing Practices Background for CCC System Highlight CCC System & Nursing Process. Discuss Value of CCC System- Concepts and/or Data for Electronic Documentation of Nursing Practice. 3
4 Nursing Informatics Background Impact on CCC System 4
5 Informatics Informatique French Word-Computer Milieu Used in Europe /Russia 1960s Used in USA 1970/80s
6 Nursing Informatics (NI) Definition (1986) It is a nursing specialty that integrates Nursing Science, Computer Science, & Information Science to manage & communicate data, into information, knowledge, & wisdom in order to advance Nursing Science (ANA, 1992; 2008). 6
7 Graves & Corcoran Data Model (1989) Enhanced by Nelson 2002 Data: Process > Information: Organize/Interpret > Knowledge: Integrate/Understand*> (Wisdom)** Understand/Apply * Model by Graves & Corcoran 1989 ** Enhanced by Nelson
8 Data Information Knowledge Wisdom DISSEMINATION of INFORMATION & KNOWLEDGE & WISDOM PRACTICE DATA COLLECTION ANALYSIS/PROCESS
9 Terminology Data Basics Terminology is a set of terms representing a system of concepts or Data (ISO-107) Data: A Single Fact Coded & Defined Database: A Collection of Related Data Relational Database: Multiple to Many Two or More Files Combined to make a New File. 9
10 Cimino-Desiderata: 9 Criteria Controlled Terminology (1998) Content: Domain Completeness Concept Orientation: Data-Atomic Level Concept Unambiguous Concept Permanence: One concept cannot be reused Unique Identifier: One unique code Formal Definition: One Unique Meaning
11 Cimino: Desiderata Criteria con t Polyhierarchy: Hierarchal Arrangement CCC RX=2 levels Compositionality: Ability to combine simple concepts into composite concepts (CCC RX two levels) Reject Not elsewhere Classified: Catchall Other not used Language Independence: Translated in other languages
12 International Standards Organization (ISO) ISO-18104=Integration of a Reference Terminology Model for Nurses (2003) Nursing Diagnoses Model Nursing Actions Model (Interventions)
13 Clinical Nursing Practice Background Impact on CCC System 13
14 Clinical Records Problem In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any comparison. Florence Nightingale Women s History Website~2003
15 Clinical Nursing Practice Theories / Models 1850s: 6 Cannons - Nightingale 1950s: 14 Activities - Henderson 1960s: 21 Nursing Problems - Abdellah 1970s: 6 Self-Care Deficits Orem 1970: ANA / Yura & Walsh -- Nursing Process -- Professional Nursing Practice
16 ANA 6 Standards of Professional Nursing Practice: Nursing Process (1970) Assessment Diagnosis Evaluation Outcome Identification Implementation Planning
17 ANA Nursing Initiatives & EHR 1986: Council on Computers in Nsg : NMDS (4 Data Types) 1990: Database Steering Committee 1991: Nursing Informatics Specialty 1992: Recognized 1 st 4 of 12 Nursing Classifications/Terminologies
18 ANA Nursing Initiatives & EHR 1994 UMLS (NLM): Integrated 6 Nursing Terminologies 1995 Developed Scope & Standards of Nursing Informatics 1995 Initiated Informatics Nurse Certification 1997 NIDSEC Vendor Approval 2000 SNOMED CT: Integrated 6 Nursing Terminologies / Overlapping Concepts
19 21 st -Century Clinical Nursing Practice EHR Needs Code Plans of Care PoCs Improve Quality/Safety Measure Outcomes Evidence-based Practice Cost-effective Care Comply- Legal Regulatory & Payer Requirements
20 Clinical Nursing Practice Data MD / RN Orders Plans of Care/ Nursing Notes Medications-Bar Codes Alerts / Risks/ Care Reminders Care Guidelines Discharge Summary / Referrals 20
21 Nursing Administration Data Patient Severity/ Acuity/ Classification Scheduling / Staff & Patients Workload / Productivity Resource Management Determine Care Costs HIPAA, Legal, & Ethical Issues 21
22 Review of Clinical Care Classification (CCC) System Version
23 CCC EHR System 1 st National Nursing Standard- Free, Coded, Interoperable Terminology HITSP/HHS: Approved 2007/2008 Available for HighTech Act of 2009 & Meaning Use (MU) Legislated Policy Care 23
24 Scope of CCC System Empirically Developed: Two Interrelated Nursing Terminologies Classified by 21 Care Components to Form a Single System for Linking 176 CCC Nursing Diagnoses to 804 CCC Nursing Interventions/Actions to 528 Outcomes.
25 CCC System Basics CCC is Nursing Terminology for Electronic Documentation of Clinical Nursing Practice based on an Information Knowledge-base Model representing the 6 Steps of Nursing Process for Professional Nursing Practice 25
26 CCC Information Knowledge-base Model Signs & Symptoms Nursing Diagnoses Nursing Outcomes Evidence Expected Outcomes Actual Outcomes To Improve To Stabilize To Support/Deteriorate Nursing Interventions Action Types Assess Care Teach Manage Improved Stabilized Supported/Deteriorated Copyright : 02/06 Created by: DHL 02/06 Virginia Saba,Ed.D, RN,FAAN, FACME & Jean Arnold, Ed.D, RN, BC
27 CCC System Framework 27
28 CCC System 4 Level Framework 4 Care Patterns 21 Care Component Classes 182 Diagnoses 549 Outcomes 198 Interventions 792 Actions
29 CCC Framework: Levels 1 & 2 4 Healthcare Patterns & 21 Care Components Healthcare Patterns Health Behavior Psychological Functional Physiological Care Component Classes Medication Safety Health Behavior Cognitive/Neuro Coping Role Relationship Self Concept Activity Fluid Volume Nutritional Self-Care Sensory Cardiac Respiratory Metabolic Physical Regulation Skin Integrity Tissue Perfusion Bowel/Gastric Urinary Elimination Life Cycle 176 Nursing Diagnoses 528 Outcome Statements 176 X 3 Qualifiers 804 Care Interventions 204 X 4 Action Types
30 CCC Adapts 6 Nursing Process Steps Assessment: Diagnoses: Outcomes: Planning: Implementation: Evaluation: 21 Care Components 176 Nursing Diagnoses 528 Expected Outcomes (3 Improve, Stabilize, Deteriorate) 804 Interventions Actions (4 Assess, Perform, Teach, Manage) (4 Action Types X 201 RXs) 528 Actual Outcomes (3 Improve, Stabilize, Deteriorate) 30
31 CCC System-Nursing Essence of Care Sign/Symptom: Difficulty Breathing (Assessment: Respiratory CC=L) Nursing DX: Respiratory Alteration = L26.0 Goal/Expected Outcome: Improve Respiratory Alteration=L Nursing Intervention/Action Types: Perform Oxygen Therapy= L36.1.2: Teach Breathing Exercises= L Actual Outcome: Respiratory Alteration Improved =L26.0.1
32 CCC Nursing Diagnoses and Outcomes Sign Symptom: Difficulty Breathing Respiratory Care Component Respiratory Alteration Breathing Exercises Goal: To Improve, Stabilize, or Deteriorate Respiratory Alteration
33 CCC Nursing Intervention/Actions Nursing Diagnosis: Respiratory Alteration Nursing Interventions Perform Oxygen Therapy Teach Breathing Exercises Actual Outcomes Respiratory Alteration: Improved, or Stabilized or Deteriorated
34 CCC Coding Structure (Data) Standardized Terminology (Data) Standardized Coded Concepts (Data) Need Codes to Classify Care Concepts Need Codes to Generate Outcomes Need Codes for Analytics, Re-Use, & Aggregate Concepts (Data) upward &/or Parse Down
35 CCC Care Analytics 35
36 CCC Care Analytics: PoC Outcome Measures Evidence-Based: Number of Nursing Interventions & Actions Care Measures: Comparison of Nursing DX Expected Outcomes (Goals) to Actual Outcomes
37 CCC Care Analytics: PoC Ouctome Measures, con t Workload & Resources: Summary of Action Types for Clinical Condition, Patient, and/or Nurse: Cost: Time Factor of Nursing Action Types with Pre-Determined Relative Value Units (RVUs):
38 Uses of Standardized Data in EHR for CCC System 38
39 Uses of CCC Coded Nursing Care Data in EHRs Standardized Documentation Collects Data Once & Used Many Times. Track Continuity of Care: Across Time, Settings, Population Groups, & Geographic Locations.
40 Uses of CCC Coded Nursing Care Data Clinical Care - Nursing Practice Reuse Data Summary Data Aggregated Data Warehouse Databases Big Data
41 CCC Care: REUSE Data Clinical Care REUSE of Data Updates Feedback for Real-Time in PoC. Dashboards: Visual Format of Data Patient-Centered &Continuity of Care PoC Referrals to Outside Sources
42 CCC Care: SUMMARY Data Develop Protocols/Pathways of Care Evaluate Providers of Care Measure Outcomes Identify Quality Indicators Determine Cost of Care Episode by Condition, Provider, & Setting
43 CCC Care: AGGREGATED Data Generate Evidence-Based Care Provide Decision-Support Data Determine Best Practices of Care Determine Care Management Compare Care Data /Cost with Other Facilities
44 CCC Care: WAREHOUSE Data & Databases Large Collection of Data Imported from Several Different Systems into one database Analyze Patient Populations Reporting of Public Health Data Compare National & International Data
45 National Database Warehouse of Coded Care Data Regional Data Warehouse Coded patient care data Super-aggregate of coded patient care data, nursingsensitive outcomes from multiple enterprises Coded patient care data Regional Data Warehouse Regional Data Warehouse Regional Data Warehouse Coded patient care data Coded patient care data National Database Warehouse Coded patient care data Coded patient care data Regional Data Warehouse Regional Data Warehouse Advise Congress Regarding Nursing Resources Taylor, 2006
46 CCC Care: BIG Data Varied Types of Digital Data Nursing Big Data Focuses:* Client: Characteristics Context: Physical, Social etc. Outcomes: Information Nursing Interventions: Content, Structure, Flow, Technology Characteristics *Effken Organizing Framework, 2003
47 Value of CCC Care PoCs in EHRs Knowledge-base: Links Nursing Diagnosis to Interventions Actions & Outcomes Develops Decision Support Generates Best-Practices Models Determines Scientific Evidence to Advance Nursing Science 47
48 CCC System Supports electronic capture of discrete patient care data for documenting the essence of care and measuring the relationship of nursing care to patient outcomes.
49
50 CCC Web Site Contact: worldnet.att.net> fication.com
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