The Clinical Care Classification (CCC) System emerged from a research project contract (HCFA No: 17C-98983/3) and was conducted by Saba, scientific members and a researchers team from 1988-1991 at Georgetown University School of Nursing. The research project was designed to develop a method to assess and classify patients to determine their resource requirements as well as measure their outcomes. To accomplish this goal, live patient data on actual resource use that could be objectively measured were collected and used to predict resource requirements.
The research consisted of a national sample of 646 healthcare facilities, randomly stratified by staff size, type of ownership and geographic location. The healthcare facility abstractors collected data on 8,961 newly discharged patients’ entire episode of hospital and home healthcare from admission to discharge. The research study collected data on all relevant variables (demographic, patient care services, encounter dates and discharge dates) considered to be predictors of patient care resource requirements (Saba, et al., 1991). The statistical analyses focused on two distinct goals:
- Conduct descriptive analyses of patient care and their services.
- Develop a nursing vocabulary/classification that could predict resource requirements and measure outcomes.
A 16-page data collection form was distributed to healthcare facilities in every state in the U.S. and Puerto Rico that volunteered to participate in the study.
Data collection
As part of the research data collection form, two questions were also used to collect narrative statements on each:
- What were the patients’ problems/diagnoses?
- What nursing services, interventions, procedures, activities, etc. were provided during the episode of illness?
These two questions provided new information on clinical nursing practice. The disposition of each nursing diagnosis on discharge was considered to be the outcome of the care and was also collected.
Classification/terminology development
In order to code and classify the narrative statements, two unique schemes had to be developed since there were no nursing classifications/terminologies in existence at that time that could be used except for medical diseases (International Classification of Diseases). Initially the narrative statements from 1,000 patient records were input into a computer for processing. The statements for both nursing diagnoses and nursing interventions for the same patient were entered into a computerized database and initially sorted using “keyword sorts” (matching of like terms together) as a means of determining common terms/concepts.
Hundreds of “keyword sorts” were also analyzed using different combinations. The terms for the nursing diagnoses and nursing interventions were not only sorted separately, but also matched together by patient. By using this technique along with other statistical analyses and clinical judgement, two sets of vocabularies were empirically developed. They were tested over and over again by Saba, the scientific members and research team until there was consistency among the concepts by all reviewers and approved by the project team. Once that occurred, two research assistants were assigned to double code the narrative statements for reliability between them using computation procedures for reliability coefficients. Once their coding was considered to be stable and have an acceptable passing coefficient, the two research assistants were allowed to code the two sets of 40,361 narrative nursing diagnostic statements and the 80,283 nursing service/intervention statements. When there was a question and/or discrepancy on a specific statement, it was set aside and brought to a research team arbitration committee to resolve and to code. Two lists were created and were too extensive to use, so the concepts for each set were then reprocessed and the actual frequencies for each of the vocabulary concepts statistically analyzed and clustered to create the initial care components classes. As a result, the original 20 and current 21 care components for the CCC of nursing diagnoses and the CCC for nursing interventions were developed and used to classify the two sets of vocabularies. Together they provide a standardized coded terminology for assessing, documenting and evaluating nursing care holistically across care settings, populations groups and geographic locations.
The Home Health Care Classification version 1.0 was initially created in a format for distribution. It was tested as a small research study at one local healthcare facility: VNA of Northern Virginia. The nursing staff collected and coded the nursing encounter of their patients’ problems/diagnoses and care interventions, activities, etc., on a specially designed research abstract form, using the initial HHCC System (version 1.0) classification. The study helped validate the reliability and usefulness of the HHCC for the documentation of clinical nursing practice. It was further used in a hospital research study collecting and coding data on a medical unit with HIV/pneumonia patients. The researchers were able to code the concepts being collected on their study clients and were found to be 99% compliant using the HHCC System. As a result, in 2004 the HHCC was formally renamed the Clinical Care Classification (CCC) System (version 1.0), including the updating of all users and all standards organizations where the HHCC was housed.