Hospital-acquired complications (HACs)

All complications on the HACs list have clinical mitigation strategies to reduce but not necessarily eliminate the risk of that complication occurring. This means that many HACs are preventable, but not all.

Development of the HACs list involved a literature review, environmental scan, clinician-driven reports, a proof-of-concept study and subsequent refinements.

Collaboration with the Independent Health and Aged Care Pricing Authority

Alongside the Independent Health and Aged Care Pricing Authority, we established a joint working party in 2012 to consider potential approaches to pricing for safety and quality in public hospital services in Australia.

The joint working party also considered how existing data that is routinely generated from the patient medical record (patient clinical data) could be used to drive improvements in healthcare safety and quality.

Safety and quality literature review

A literature review of existing Australian and international approaches to pricing for safety and quality was undertaken in 2013 and found that:

• linking quality and safety with hospital funding is being considered and implemented by many countries, using a variety of approaches
• the evidence for the material impact of such schemes on patient outcomes remains equivocal
• evidence demonstrates that the provision of relevant and timely clinical information to clinicians and managers is an effective driver of safety and quality improvement.

Environmental scan

An environmental scan reviewed the use of patient clinical data to drive safety and quality improvement and concluded:

• patient clinical data can be used as a screening tool to indicate areas of concern, or in need of attention, with regards to safety improvement
• the use of patient clinical data should be regarded as a useful first step in identifying potential safety issues but should not be the only method used.

Development of the draft list of high-priority HACs

A clinician-driven process helped develop the HACs list.

The initial development of the list involved:

• building on developments in patient safety monitoring – including the introduction of the condition onset flag, as a means of differentiating between conditions that arise before or during an admitted episode of patient care, and the development of the classification of hospital-acquired diagnoses (CHADx)
• a review of the safety literature and hospital incident reports to identify complications that were cited as having a material impact or being preventable
• an analysis of hospital-acquired diagnoses and their effect on case complexity and resource use
• Iterative identification of the highest priority complications by a clinical expert reference group – comprising clinicians, key hospital safety experts, clinical administrators and consumer representatives – based on criteria of preventability, patient impact (severity), health service impact and clinical priority.

The report for this work recommended that the HACs list be supported as a national set of complications for local monitoring and review, subject to broader consultation and testing.

Proof-of-concept study

A proof-of-concept study to explore the validity of using the HACs for quality and safety improvements was undertaken over 2014 and 2015 in seven public and eight private hospitals.

The study assessed:

• the accuracy and completeness of patient clinical data for over 5,000 hospital records (accuracy testing)
• the feasibility and utility of using the HACs list for monitoring and reporting patient complications using an interactive reporting tool (utility testing).

The study concluded that:

• the general concept of using patient clinical data to derive clinical measures for safety and quality purposes is useful and acceptable to clinicians
• the specific concept of using patient clinical data to detect and report HACs is useful and acceptable to clinicians
• Patient clinical data is sufficiently accurate to support implementation of measurement and monitoring of HACs for safety and quality monitoring, notwithstanding that there are areas for improvement in data quality. Key areas for coding improvement are the accuracy of the condition onset flag and selected HACs – falls with fracture, iatrogenic pneumothorax, medication complications and persistent incontinence
• monitoring and reporting on HACs at the hospital level can be used by clinicians to detect patient safety problems and develop clinical risk mitigation strategies to reduce (but not necessarily eliminate) the risk of the complication occurring
• clinicians will make use of reported data if they have confidence in the measures of safety and quality and have access to analytical reporting tools and data expertise.

Finalisation of the HACs list

The HACs list was refined based on:

• the findings from the proof-of-concept study
• a clinical reference group coding review
• investigation of complications from clinical domains that required specialist advice.

Version one of the HACs list was released in August 2016.

The HACs list was developed through a health professional -driven process to use existing administrative data for the purpose of safety and quality improvement.

The development of the HACs list included:

• health professional  engagement and consultations
• literature reviews
• proof-of-concept testing with public and private hospitals

Prioritisation criteria

Under the National Health Reform Agreement (NHRA) and subsequent Addendums, the incorporation of the HACs into the national public hospital funding model (for the Commonwealth’s contribution) was agreed to by all state, territory and the Commonwealth governments in 2017.

For the Commonwealth’s contribution, the pricing signal and subsequent HACs funding adjustments are risk adjusted and updated annually, by the Independent Health and Aged Care Pricing Authority (IHACPA). The HACs risk adjustment methodology and funding adjustments are published by IHACPA as part of the annual National Efficient Price Determination and National Pricing Model Technical Specifications.

The IHACPA has published the Hospital Acquired Complications Fact Sheet, to provide additional advice on the safety and quality funding approaches.

The pricing signal is applied to reflect a proportion of the additional cost for care delivered associated with that complication. IHACPA’s case study example outlines how the HAC risk adjustment model is applied to an individual episode of care in terms of the National Efficient Price. The Commonwealth’s contributions to public hospital funding are determined by the National Health Funding Body (NHFB), and based on growth in activity between years. The HAC adjustment is incorporated in these growth calculations by the NHFB.

Non-Commonwealth funding adjustments relating to HACs, along with overall funding distributions to hospitals, are implemented, and incorporated differently across States, Territories and health services. Funding contributions can be calculated using activity-based funding, block funding or a combination of both. Furthermore, clause A94 of the 2020-25 NHRA Addendum states:

• there will be no requirement for Local Hospital Networks to be paid the full national efficient price if the State considers that a lower payment is appropriate, having regard to the actual cost of service delivery and the Local Hospital Network’s capacity to generate revenue from other sources.

For details on how your hospital or health service is impacted by HACs funding adjustments, please contact the appropriate unit within your health service, Local Health District or state and territory health department.

Documentation to signal workflow

If a HAC is not documented and not coded as part of the episode of care, this disadvantages a service in multiple ways.

The resources required to provide care to manage the HAC may not be captured in the funding formula, nor is there an explanation for any extended length of stay.

Discouraging documenting HACs is more likely to diminish funding streams. Health services may be worse off from a funding perspective, let alone the medico-legal consequences of not documenting a patient’s diagnosis. 

A health service is better off documenting a HAC to receive the greatest proportion of funding, even if a small proportion is adjusted and potentially withheld.

Consistent and routine documentation and coding of HACs also allows health services to monitor, target and improve the safety and quality of patient care.

Overall, this results in better patient outcomes and improves financial efficiencies for health services

One of the key markers and potential tools that should be used to support reviewing and interpreting HACs data, is the identification of variation in outcomes and results.

This approach aligns with and is supported by our National Safety and Quality Health Service Standards. Our user guide for reviewing clinical variation supports the review of variation.

Variation can be masked when reviewing data at a whole of system level (for example, at a health service or facility level) and may only be visible with targeted integration. When reviewing HACs data within a facility, it is important to consider aspects such as patient demographics, Casemix, the structure of the facility and varying care type settings (such as acute versus subacute care).

To support the review and interpretation process, the HACs data may include looking at HAC numbers or rates, by patient age, sex and comorbidities, clinical specialty, or ward, for example. This process and interpretation should be supported by technical experts, clinicians and hospital managers within the service, to ensure the relevance and actionability of the HACs data produced.

When comparing HACs data between health services or facilities, it is imperative to consider differences between facilities, to provide context to any comparisons. This may involve comparing similar facilities (based on hospital peer groups, services provided and clinical specialties), appropriate risk adjustment or standardisation to cater for differing Casemix and patient populations.

Not all health services and jurisdictions have the ability, or ready access, to HAC data, from other services, to provide context to local results.

To enable national comparisons of HAC rates, national and peer group goal rates are provided to support local level interpretation and quality improvement processes relating to HACs.

Our HACs literature library brings together tools, resources and literature to support reduction in HACs.

We endeavour to update this list as required, or when new evidence and resources become available.