Development of the hospital-acquired complications (HACs) list

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 Hospital Pricing Authority

The Commission and the Independent Hospital Pricing Authority established a Joint Working Party (JWP) in 2012 to consider potential approaches to pricing for safety and quality in public hospital services in Australia.

Measurement is foundational to advancing safety and quality improvement. To understand what the major safety issues are across the care continuum, meaningful metrics are required to identify, measure and proactively mitigate patient safety risks. The JWP therefore 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. It 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. It concluded that:

  • 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 a national list of high-priority HACs. A HAC refers to a patient complication for which clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring. 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 HACs list was released in August 2016. The HACs list and supporting materials are available for download.