Eliminating Hospital Acquired Conditions (HACs): An HCA Multi-Track Improvement Project

On February 8, 2006, the President signed the Deficit Reduction Act (DRA) of 2005. Section 5001(c) of DRA requires the Secretary to identify hospital acquired conditions (HACs) that: (a) are high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis and (c) could reasonably have been prevented through the application of evidence-based guidelines. Hospitals will no longer receive payment for HACs unless there is medical record documentation indicating that they were present on admission (POA).

HAC Improvement Project

HCA has launched a 16-week improvement project designed to engage facilities specifically around their “opportunity” areas. The 6 categories of HACs that HCA has selected for focus include:

  • Foreign Object Retained After Surgery
  • Stage III and IV Pressure Ulcers
  • Falls and Trauma
  • Manifestations of Poor Glycemic Control
  • Catheter-Associated Urinary Tract Infection (UTI)
  • Vascular Catheter-Associated Infection

The first step of the project was the completion of a gap analysis for each of the six HACs. Team leaders completed the GAP analyses with an interdisciplinary group and submitted to the Division VP of Quality.

HAC Team Leaders

Hospital Acquired Condition Team Leader
Foreign Object Retained After Surgery Cheri Miller, RN Director, Main OR & Annie Meeks, Director, Spine and Total Joint Service Line
Stage III and IV Pressure Ulcers Adam George, Director Therapy & Terri Arrigo, Certified Wound Ostomy Nurse
Falls & Trauma Roxanne Hansen RN, Director, 4th and 6th Floor and Education
Glycemic Control Merebeth Richens, RN ICU Manager
Catheter-Associated UTI Charlene Lopez, Infection Preventionist
Vascular Catheter-Associated Infection Charlene Lopez, Infection Preventionist

Physicians and LIP documentation of Present on Admission (POA) are key. If a patient has a related pre- hospital condition, for example, diabetes, fall at home, pressure ulcer on admission, suspected urinary tract or vascular catheter infection on admission, documentation by the physician or LIP will clarify the condition, and it will not be coded as hospital acquired. The CDI team will communicate with physicians, and when appropriate, place query forms on the chart. If you have questions, please contact Donna Lucas, Director of Health Information Management at (720) 225-1046 or Lisa Bennett, AVP of Quality and Risk, at (720) 225-1834.