Background

Clinical Care Classification (CCC) System emerged from a Research Project Contract (HCFA No: 17C-98983/3) and conducted by Saba, Scientific Members, and Researchers Team (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 patient’s entire episode of hospital and home health care 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 to: a) Conduct descriptive analyses of patient care and their services and b) Develop a nursing vocabulary/ classification that could predict resource requirements and measure outcomes. A sixteen page data collection form was distributed healthcare facilities in every state in the USA and Puerto Rico who volunteered to participate in the study.

Data Collection

As part of the research data collection form two open-ended questions were also used to collect narrative statements on each: a) patient’s problems/ diagnoses and b) nursing services, interventions, procedures, activities, etc. provided during the episode of illness. These two open ended questions provided new information on clinical nursing practice. The first question designed to collect nursing diagnoses and/or patient problems assessed the major reason a patient needed medical and nursing care. The disposition of each nursing diagnosis on discharge was considered to be the outcome of the care and was also collected. The second question collected all skilled nursing services, interventions, activities, etc. provided during the episode of care.

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 a 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), were sorted and clustered 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 and the Scientific Members and Researchers 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 considered 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 re-processed 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 and in a format for distribution. It was tested as 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 (V 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 % compliance using the HHCC System.  As a result, in 2004 the HHCC was formally renamed the Clinical Care Classification (CCC) System (V 1.0), including the updating of all users and all standards organizations where the HHCC was housed.