Hospital acquired conditions (HAC) reduction program

Vascular access management blog


Hospital acquired conditions (HAC) reduction program, your frequently asked questions answered

Aug 13, 2021

What is the Hospital-Acquired Condition (HAC) Reduction Program?

The Hospital-Acquired Condition Reduction Program (HACRP) is a CMS initiative that ties Medicare reimbursement to hospital-related patient safety issues. Specifically, the program strives to improve healthcare quality by reducing the incidence of hospital-acquired infections (HAIs) and other adverse events.1

In practice, HACRP operates as a pay-for-performance program. Every year, the lowest performing 25% of all subsection (d) hospitals are penalized with a 1% reduction in Medicare payments. For health systems and hospitals that serve thousands of people each year, a 1% penalty can mean millions of dollars of lost income. Beyond the financial ramifications, CMS is also required by law to publish hospitals’ HAC scores publicly.1

What is a subsection (d) hospital?

A subsection (d) hospital is defined as an acute care hospital that provides inpatient services for less than 25 days (on average). A subsection (d) hospital is not a psychiatric or rehabilitation hospital, nor is it one that is predominantly focused on the treatment of cancer patients.2

How is the HAC Score calculated?

Hospitals across the United States are evaluated for the HACRP based on a scoring methodology that takes into account various healthcare quality measures. The total HAC Score for each hospital is calculated using two major healthcare quality measures: The CMS Recalibrated Patient Safety Indicator (CMS PSI 90) and the CDC’s Prevention National Healthcare Safety Network (CDC NHSN) for healthcare-associated infection measures.3

The Total HAC Score is calculated as an equally weighted average of the CMS PSI 90 and CDC NHSN healthcare-associated infection measures described above.3

  1. The components of the CMS PSI 903 are:
    1. PSI 03 – Pressure Ulcer Rate
    2. PSI 06 – Iatrogenic Pneumothorax Rate
    3. PSI 08 – In-Hospital Fall with Hip Fracture Rate
    4. PSI 09 – Perioperative Hemorrhage or Hematoma Rate
    5. PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate
    6. PSI 11 – Postoperative Respiratory Failure Rate
    7. PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
    8. PSI 13 – Postoperative Sepsis Rate
    9. PSI 14 – Postoperative Wound Dehiscence Rate
    10. PSI 15 – Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate
  2. The CDC NHSN HAI measures3 include:
    1. Central Line Associated Bloodstream Infections (CLABSIs)
    2. Catheter-Associated Urinary Tract Infections (CAUTIs)
    3. Surgical Site Infection (SSIs), specifically for colon surgeries and hysterectomies
    4. Methicillin-Resistant Staphylococcus aureus (MRSA) bacteremia
    5. Clostridium difficile infections (CDI)

The CDC calculates the standardized infection ratios (SIR) for each of these measures over a given time period. The SIR compares the actual number of reported hospital-acquired infections (HAIs) with what would be expected for a given population at baseline.4 An SIR of greater than 1 indicates that more HAIs were observed than predicted. Conversely, an SIR value of less than 1 indicates that fewer HAIs were observed than predicted.4

SIR = Observed HAIs ÷ Predicted HAIs

Following these calculations, the CMS sends confidential Hospital-Specific Reports (HSRs) to hospitals, giving hospitals 30 days to review their HACRP data, submit questions about the calculations, and request corrections to the scoring.3 CMS will then publicly report the hospital’s HACRP data.

What is a good HAC Score?

Generally, if a HAC Score is higher, it indicates that the hospital is not performing well. In the 2020 fiscal year, the cutoff for the Total HAC score to avoid a penalty was 0.3306.3 Thus, hospitals that had HAC Scores below 0.3306 were considered to have good HAC Scores.

How can I improve my hospital’s HAC Score?

Here are 3 tips on how to improve your hospital’s HAC Score.

  1. Leverage data to reduce the incidence of HAIs. The first step is understanding the number and type of infections that occur in your hospital. This information, combined with the data collected by the CDC’s NHSN,5 can drive targeted changes to your infection control program, focusing the attention and efforts of infection preventionists, nurses, and the healthcare team more broadly.
  2. Review cases and find the source of hospital-acquired conditions. With this macro data in hand, it’s time to review specific trends and cases. If you see an uptick in CLABSIs, it may be time to review central line insertion practices as well the practices of healthcare personnel who provide daily care to patients with central lines. Narrowing in on the source of CLABSIs may allow leaders to institute solutions that can minimize these safety issues.
  3. Accurately capture “present on arrival” (POA) conditions. Processes that systematically document pre-existing conditions or “present on arrival” (POA) conditions are key to improving your hospital’s HAC Score. If pre-existing conditions are not captured correctly, they may be included in a hospital’s HACRP data. This negatively impacts HAC Scores. To prevent this from happening, put the appropriate coding systems in place to capture data on admission.


The Centers for Medicare and Medicaid Services. Hospital-Acquired Condition Program. Accessed online April 28, 2021.

The United Stated Social Security Administration. Payment to hospital for inpatient hospital services. Section 1886. [42 U.S.C 1395ww]. Accessed online April 28, 2021.

The Centers for Medicare and Medicaid Services. Hospital-Acquired Condition Reduction Program Fiscal Year 2024 Fact Sheet. October 2023. Accessed online on December 11, 2023.

The Centers for Disease Control and Prevention - National Center for Emerging and Zoonotic Infectious Disease. The NHSN Standardized Infection Ratio (SIR) Guide. March 2019.

The Centers for Disease Control and Prevention. Healthcare-associated infections. Accessed December 11, 2023.

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