Expert spotlight: Tackle hospital-acquired conditions with a prevention team

Nurse Leader Insider, March 9, 2009

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This week, Laura J. Weber, RN, BSN, MBA/HCM, director of quality management, and Melissa A. Ormiston, assistant controller, from Medical City Dallas Hospital and Medical City Children's Hospital in Dallas offer some direction for initiating hospital-acquired condition (HAC) prevention measures.

Q: Several members of hospital staff and I recently formed a team to drive efforts to minimize HACs at my facility. Any tips for getting started?

A: 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 determine 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

Editor's note: Do you have a question for our experts? Email your queries to Editor Keri Mucci at and see your name in print next week! In the meantime, head over to our Web site and view a growing collection of advice from our experts.

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