Clinical Care Classification System

Clinical Care Classification System

The Clinical Care Classification System (CCC) is an American Nurses Association-recognized comprehensive, coded, nursing terminology standard that can be used to support the documenting of nursing practice via the Electronic Health Record. In 2007, the CCC was accepted by the Department of Health and Human Services as the first national nursing terminology. The CCC is a unified nursing terminology following the Nursing Process for professional clinical decision making and is designed for computer processing. The computable structure of the CCC System allows nurses, allied health professionals, as well as researchers, to determine care needs (resources) workload (productivity), and outcomes.

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Open Architecture
Designed for computer-based systems - EHR, CIS, & PHR
Tested and applicable in ALL healthcare settings
Interoperable with ANSI HL7
Integrated in SNOMED © CT and UMLS
Atomic-Level Concepts
Conforms to Cimino criteria for a standardized terminology
Coded standardized framework for electronic documentation, retrieval & analysis
Codes based on ICD structure for information exchange promoting interoperability
Designed for determining care costs
Integrated in the Metathesaurus of the Unified Medical Language System (UMLS) of the National Library of Medicine (NLM) and SNOMED CT
Integrated in the Cumulative Index to Nursing & Allied Health Literature® (CINAHL)
Approved as a terminology by the American National Standards Institute (ANSI) Standard Development Organization (SDO) Health Level Seven (HL7®).
Used in the Clinical LOINC System for documenting diagnoses outcomes
Tested as an international nursing standard based on the "An Integrated Reference Terminology Model for Nursing" approved by the International Standards Organization (TC-215) in October 2003.
Concept terminology with online source files so public and private organizations may harmonize nursing information formats for the cross organizational sharing of information.
One of the contributed terminologies used as the basis for the original alpha version of the International Classification of Nursing Practice (ICNP®) developed by the International Council of Nurses (ICN).
Indexed to the MEDCIN ® terminology through a contextual hierarchy to the full array of medical terminology standards and concepts with intelligent prompting (IP). The indexing allows for the presentation and documentation of relevant clinical symptoms, history, physical findings, and diagnoses to the CCC nursing terminology from the CPT®, DSM, ICD, LOINC®, RxNORM, SNOMED CT® and others for virtually any clinical condition.

The CCC System is a nursing terminology of discrete atomic-level data elements that encompasses nursing diagnoses, interventions, and outcomes capturing the essence of patient care in all health care settings. The CCC System describes the six steps of the Nursing Process: assessment, diagnoses, outcomes identification, planning, implementation, and evaluation (the standard of professional nursing practice recognized by the ANA) in a coded, standardized framework to support the exchange of nursing information and makes available for data retrieval and analysis in the electronic health record and health information record systems database.

The Clinical Care Classification System is a standardized, coded nursing terminology framework specifically designed to electronically document nursing practice and consists of two interrelated terminologies: the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Action Types; both of which are classified by 21 Care Components. The Clinical Care Classification System was developed from a research study conducted by Dr. Virginia K. Saba, EdD, RN, FAAN, FACMI and a research team through a contract with the Health Care Financing Agency (HCFA), currently known as the Centers for Medicare and Medicaid Services (CMS). The objective was to develop a computerized method for assessing and classifying patients for the prediction of nursing resources needs and for evaluating the outcomes of care. “To accomplish this goal, data on actual resource use, which could objectively be measured, were collected and used to predict resource requirements” (Saba, 2002). The CCC research team consisted of home health experts, a statistician, a systems analyst, and a national advisory committee. Dr. Saba and colleagues conducted a pilot study, designed a framework, established a methodology, and developed an abstract form consisting of 73 pre-coded variables (Saba, 2002). Then, the methodology was applied to a national sample of home health agencies that provided all services and products used to restore, maintain, and promote physical, mental, and emotional health to Medicare home health patients (Spradley & Dorsey, 1985). The CCC System was developed from retrospective research data from 8,967 patient records from a sample of 800 organizations randomly stratified by staff size, type of ownership, and geographic location. The organizations represented every state in the nation including Puerto Rico and the District of Columbia (Saba, 1992). Dr. Virginia K. Saba, EdD, RN, FAAN, FACMI and the research team spent more than a year analysing and coding the research from 10,000 patient records from which the team obtained more than 70,000 statements focusing on nursing interventions and actions provided to patients as well as 40,000 diagnostic conditions and problems describing patient care needs. The empirical analysis was through ‘permuted word sorts’ designed to depict and distill the “essence of nursing care” (Saba, 2007). By using ’key- word-sorts’ to analyze the phrases, the research team distilled their findings into “essence of nursing care concepts”, and developed the CCC System (Saba 2005).

The CCC System is a standardized framework of the four levels designed to allow nursing construct data to flow upward as well as downward. At the highest level the CCC System Framework consists of four healthcare patterns (Saba, 2007):

health behavioral
functional
physiological
psychological

Each represents a different set of Care Components. The second level consists of the 21 Care Components which serve to classify the two terminologies and defined as a cluster of elements that depict one of four healthcare patterns. The third level consists of:

182 nursing diagnosis concepts representing concrete patient problems
792 nursing interventions and actions (198 interventions each with one of 4 action types (assess, perform, teach, and manage) each depicting a unique single atomic-level concept

The fourth level is represented by the expected and actual outcomes 182 diagnoses each with one of three outcomes for Expected Outcome (Saba, 2007, p. 154):

“improve or resolve patient’s condition”
“stabilize or maintained patient’s condition”
“support deterioration of patient’s condition"

And one of three outcomes for Actual Outcome:

“improved or resolved patient condition”
“stabilized or maintained patient’s condition
“deteriorated or died”

The CCC System uses a five-character structure to code the two terminologies: (1) CCC of Nursing Diagnoses and Outcomes and (2) CCC of Nursing Interventions and Actions. The CCC coding structure is paced on the format of the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision: Volume 1, WHO, 1992. The coding strategy for each terminology consists of the following (Saba, 2007):

First position: One alphabetic character code for Care Component (A to U);
Second and Third positions: Two-digit code for a Core Concept (major category) followed by a decimal point;
Fourth position: One-digit code for a subcategory, if available, followed by a decimal point;
Fifth position: One-digit code for: one of three Expected or Actual Outcomes and /or; one of four Nursing Intervention Action Types.
There are 4 CCC Action Types were derived from the frequencies analyzed in the research study of 70,000 textual phrases described above.

The significance of the Clinical Care Classification System (CCC) is that this nursing terminology completes the missing link needed to address nursing contribution to healthcare quality. The CCC provides the data needed to address nursing documentation using a structured, coded terminology. Thus far, nursing has conducted separate research studies using different variables and/or methods without a standardized terminology resulting in different findings that cannot be compared. If a standardized nursing terminology were used, studies could compare findings across population groups and settings. For example, the CCC System has been shown to be valid for nursing documentation in different acute-care hospital settings by several different researchers such as Holzemer (1999) and Moss, Damrongsak and Gallichio (2005). Further, since the Clinical Care Classification System is available as a national nursing standard, the CCC may be used to support nursing practice and generate comparable information across healthcare settings for the care process.

Ultimately, the Clinical Care Classification System (CCC) is a nomenclature of discrete atomic-level data elements about the nursing process that encompasses nursing assessment, diagnosis, intervention, actions, and actual and expected outcomes. The CCC System is an electronic healthcare information system standard to identify the contribution of nursing to patient outcomes for improved healthcare services. The coded nursing diagnoses, interventions and outcomes immediately downloadable and readily available for use by organizations interested in describing and communicating the electronic documentation of nursing practice today.

The benefits of Clinical Care Classification System (CCC) data elements are that information technology analyst, healthcare managers, and nursing are able to use the common units of data to use a terminology in the public domain for health information systems and applications as well as realize a significant and immediate return on investment for IT system products. Using the CCC nursing terminology should:

Accelerated electronic health information system software development
Increase employee productivity (standardized documentation)
Provide standardized consistent health data for interventions and research
Provide re-usable health data for cross-organization comparisons
Reduce healthcare cost from improved, documented outcomes by intervention
Reduce level of effort in unnecessary computer system data element development.

The Clinical Care Classification System (CCC) is the only nursing terminology specifically developed for computerization e.g. electronic healthcare information systems and computer-based patient records (CPR) from research which collected live patient care data. The CCC follows the six 6 steps of the Nursing Process:

Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation and specifically links nursing diagnoses to nursing interventions to nursing outcomes.

Nursing care may be the most critical factor in a patient’s treatment and recovery (Gordon, 2005) and understanding the impact of care on patient outcomes may be the key to improving quality in today’s healthcare system. The computable structure of the Clinical Care Classification System (CCC) in the public domain (copyright permission) promotes the system upgrades of existing electronic healthcare information systems. The system architecture of the CCC offers a return on investment with discrete, atomic-level data on the impact of nursing care to care quality, as well as productivity (workload), resources (staffing), and outcomes management. The objective of nursing informatics is to improve nursing practice through the creative use of technology.

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1. www.sabacare.com 2. www.clinicalcareclassification.com 3. Saba, V. K., & McCormick, K. A. (2011). Essentials of Nursing Informatics (5th ed.). New York, NY: McGraw-Hill. 4. Gartee, R. & Beale, S. (2011). Electronic Health Records and Nursing. Upper Saddle River, NJ: Pearson/Prentice Hall. 5. Whittenburg, L. (2009). Nursing Terminology Documentation of Quality Outcomes. Journal of Health Information Management, 23, (3):51-5. 6. Feeg, V. D., Saba, V. K., & Feeg, A. (2008). Development and testing of a bedside personal computer (PC) Clinical Care Classification System for nursing students using Microsoft Access, Computers in Nursing, 26 (6), 339-49. 7. Saba, V. K. (2007). Clinical Care Classification (CCC) System manual: A guide to nursing documentation. New York: Springer Publishing. 8. Saba, V. K., & Taylor, S. L. (2007). Moving past theory: Use of a standardized coded nursing terminology to enhance nursing visibility. Computers in Nursing, 25 (6), 324-331. 9. Gordon, S. (2005). Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Ithaca, New York, Cornell University Press. 10. Moss, J., Damrongsak, M., & Gallichio, K. (2005). Representing critical care data using the Clinical Care Classification. In C. P. Friedman, J. Ash, & P. Tarcy-Hornoch (Eds.), American Medical Informatics Assocation 2005 Proceedings: CD-ROM (p.545-549). Washington, Dc: OmniPress, Omipro-CD. 11. Parlocha, P. K. & Henry, S. B. (1998). The usefulness of the Georgetown Home Health Care Classification system for coding patient problems and nursing interventions in psychiatric home care. Computers in Nursing, 16, 45-52. 12. Saba, V. K. (2005). Clinical Care Classification (CCC) of Nursing Interventions. Retrieved December 15, 2005, from http://www.sabacare.com. 13. ANSI/HISB (1998/1999) Home health care classification (HHCC) of nursing diagnosis and nursing interventions. Inventory of Clinical Information Standards. Washington, DC: ANSI. 14. Holzemer, W. L, Henry, S. B., Dawson, C. Sousa, k, Bain, C. & Hsieh, S. F. (1997). An evaluation of the utility of the home health care classification for categorizing patient problems and nursing interventions from the hospital setting. Studies in Health Technology & Informatics, 46, 21-26. 15. Saba, V. K. (1995) A new paradigm for computer-based nursing information systesm: twenty care components. In R. A. Greenes, H. E. Peterson, & D. J. Proti (eds.), Medinfo ’95 Proceedings (p. 1404-1406), Edmonton, Canada: IMIA. Saba, V. K. (2002). Nursing classifications: Home Health Care Classification System (HHCC): An Overview, Online Journal of Issues in Nursing. Retrieved March 16, 2011 from http://nursing world.org/ojin/tpc7/tpc7_7htm. 16. Saba, V. K. & Zuckerman, A. E. (1992). A new home health classification method. Caring Magazine, 11, 27-34. 17. Saba, V. K. (1991). Home health care classification project. Washington, DC: Georgetown University (NTIS No. PB 92-177013/AS) 18. Saba, V. K. (1992). The classification of home health care nursing diagnoses and interventions. Caring, 10(3), 50-57. 19. Spradley, B. W., & Dorsey, B. (1985). Home health care. In B. W. Spradley (Ed.), Community health nursing. Boston, MA: Little, Brown & Co.

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