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Myself and other hospital staff recently formed a team to drive efforts to prevent hospital-acquired conditions (HACs). Any tips for getting started?

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The team should begin by reviewing the effects of HACs at your facility. The next step is to pull baseline data to begin establishing benchmark metrics. Benchmarking data will establish where your organization already stands with HACs, which will help you map out your progress. In other words, you can then review where you came from and where you have progressed.

To start, you will need to know how many HACs your facility currently has in order to see whether your team's plan to reduce the number of HACs is working. You can also use your benchmark data to track length of stay, cost, and reimbursements. If the organization has access, the past year's worth of data (all patients with HACs) should be reviewed and analyzed. If you cannot review all data, you should at least review a sample of 30% of the population. As a starting point, the team can pull patient information for those patients with ICD-9 codes that represent all the HAC conditions.

Consider the following areas when starting the data collection process at your facility:

  • Number of cases
  • Average length of stay
  • Sex
  • Age
  • Payer mix
  • Diagnosis-related group
  • Average charges
  • Average payment
  • Average cost

—Laura J. Weber, RN, BSN, MBA/HCM and Melissa A. Ormiston