Hospital acquired complications and documentation enhancement project

Published 27 May 2020. Last updated 12 June 2020.

This project is designed to clarify the validity of hospital acquired complications (HACs) as coded via clinical coding.

It aims to review and assess the HACs, highlighting areas of clinical practice which require training or overhaul to reduce production of HACs.

Documentation education will also take place to boost content-related activity, and to support the attraction of optimum National Weighted Average Units (NWAU). The NWAU is a common currency to describe an amount of clinical activity, with a weighting applied that takes account of case mix and complexity.


  • To improve clinical practice in areas which produce the highest rate of HACs and mitigate their generation.
  • To educate staff as to the importance of documentation and activity content to maximise funding for our efforts. Activity content consists of a description of the actual nursing activities performed for the patient. It explains the depth and complexity of that activity, why it was needed and how it has helped the patient. It demonstrates the amount of work being expended by nursing staff for their patient load. The higher the demonstration of activity, the clearer the Ministry of Health can understand the degree of care required for the facility demographic, in order to make funding based decisions.


  • Improved clinical practice with a higher standard of clinical patient-centred care.
  • Fewer HACs, which is a better outcome for the patient and organisation as length of stay is optimal.
  • Enhanced and more professional documentation which reflects, the activity within the activity based funding (ABF) framework. The ABF is a way of funding hospitals whereby they get funded for the number and mix of patients they treat. If a hospital treats more patients, it receives more funding. Because some patients are more complicated to treat than others, ABF also takes this in to account.
  • ABF funding should support timely access to quality health services, improve the value of the public investment in hospital care and ensure a sustainable and efficient network of public hospital services. The ABF payments should be fair and equitable, including being based on the same price for the same service across public, private or not for profit providers of public hospital services.
  • By enhancing this professional nursing documentation there is not only a better recorded clinical picture of the patient’s care, but there are also key activities noted, which increase the opportunity for funding via NWAU increments.


  • The local health district was in financial deficit with increasing rates of HACs.
  • Clinical coding was approximately five months behind, which had an impact on financial reporting and efficiency of process.
  • Nursing and allied health documentation, though clinically viable, did not fully reflect the extent of activity put into our patient needs, missing out on NWAU.
  • Condition onset flags were not always identified in emergency departments which generated an incorrect HAC during the patient’s stay, which brought about financial penalties. The condition onset flag is a means of differentiating those conditions which arise during, or arose before, an admitted patient episode of care. Having this information to hand provides an insight into the kinds of conditions patients already have when entering hospital and what arises during the episode of care.


  • Delivery of education and training sessions to address what HACs are and how activity based funding/clinical coding works.
  • Delivery of education and training sessions to address sub-optimal documenting and develop ways to enhance and improve content, with the inclusion of activity.
  • Increased focus on clinical coding and incorporating them into staff education.
  • Issuing HAC packs for the wards, to advise on HACs and how to avoid them.
  • Creating ‘docububbles’, which are prompt sheets to ensure important inclusions appear in the documentation.


Sustained - The project has been implemented, is sustained in standard business.


Clinical Excellence Commission

Implementation sites

  • South East Regional Hospital
  • Pambula District Hospital


  • Three Plan, Do, Study and Act (PDSA) cycles were implemented to evaluate the outcomes.
  • Audits of documentation were also carried out.
  • Results to date show an overall improvement in documentation content, with a mitigation of HAC and increase of NWAU of over $1 million at the time of submission to the Agency for Clinical Innovation.

Lessons learnt

  • Inclusive documentation does not have to be lengthy and convoluted. Instead, concise information can still attract NWAU when properly written.
  • Hospital acquired complications can be avoided when staff are aware of what they are and how easily they can be caused.
  • Some HACs are not 'real', such as side effects of insulin and a diabetic regime which can lead to a hypoglycaemic episode. This is an effect and not a HAC, yet it is coded out as such, and carries a financial penalty.

Further reading


Tracey Doran-Robertson
Registered Nurse
South East Regional Hospital
Southern NSW Local Health District
Phone: 0431 863 931


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