Virginia Saba, EdD, RN, FAAN, FACMI, is an internationally renowned pioneer in nursing informatics and the developer of SabaCare, or the Clinical Care Classification (CCC) System, which serves to advance the science and practice of nursing. She recently entrusted custody of the CCC System to HCA Healthcare.
What is SabaCare?
SabaCare is a system of globally standardized nursing terminology that enables electronic documentation of clinical nursing practice. The coding structure is similar to other universal medical library systems, such as the more widely known ICD-10 medical procedural and diagnosis code classification system. Each concept code is made up of five alphanumeric characters for information exchange and operability. SabaCare is designed to align with ICD-10 and other structured terminologies.
On the CCC System website, there is a helpful code-builder that walks the user through the six steps of the nursing process recommended by the American Nurses Association: assessment, diagnosis, outcome identification, planning, implementation and evaluation.
The nurse can enter the information and get the corresponding code to nursing diagnoses or nursing interventions.
As a major employer of nurses in the U.S., HCA Healthcare is committed to continuing the legacy of SabaCare by maintaining and developing the system.
Under the leadership of Jane Englebright, RN, Ph.D., CENP, FAAN, Chief Nurse Executive and Senior Vice President, and with Dr. Saba’s support and direction, HCA Healthcare embedded the CCC structured terminology into the electronic health records (EHR) at nearly all of its 186 hospitals across the country over the last seven years. The original workflows that HCA Healthcare used are available to the public in the library at the Sigma Theta Tau International Honor Society of Nursing in Indianapolis.
Why is it important to have structured data?
In short, structuring data makes it mean something. Consider how many different ways there are to state a patient’s weight, for example. A nurse could write “pounds” or “lbs.” Other countries measure weight in kilograms. The CCC System is an international semantic web where all of these related terms are standardized so that the meaning is the same for even comparison. SabaCare has been translated into nine languages and counting.
RN, Ph.D., ACNP
The CCC System solves another problem as it integrates with all other EHRs. There are many EHR systems (also called electronic medical records, or EMRs), and each has its own unique branded language and codes. “For example, a patient may see a neurologist who has the NextGen EMR, and her neurosurgeon has Meditech,” explains Dan Roberts, RN, Ph.D., ACNP, Vice President Nurse Performance and Care Delivery at HCA Healthcare. “The CCC System translates these terminology structures in order to tell the patient’s story.”
How does the approach benefit healthcare?
SabaCare was founded in evidence-based clinical documentation, and Roberts indicates this leads to evidence-based care. “If a hospital wanted to know more about its rates of hospital-acquired infections and how nursing is informing reduction efforts, it can learn from the documentation through dashboards, alert systems and real-time indicators for the next process in nursing practice,” he says. Earlier this year, nursing leaders at HCA Healthcare used the CCC System to identify patients who were on higher levels of oxygen prior to needing a ventilator.
HCA Healthcare built real-time performance visibility into its EMR, so clinicians know whether they’re meeting the evidence-based standard of care for each patient, and any needed improvements can be addressed. “We have performance management tools that allow nurse leaders to coach nurses on best practices, so there is a continuous learning cycle,” says Roberts. “We’re using the data to improve nurse competencies so that we have optimal patient outcomes.”
The CCC System is free and available to any organization where patient care is performed, including hospitals, schools, nursing facilities and rehabilitation centers. With support from HCA Healthcare, the CCC System is integrated into an organization’s EHR documentation system such as EPIC or Cerner.
For more information on how to make SabaCare work for your facility, visit careclassification.org.
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