Hospital Wide CI set update

The hospital-wide clinical indicator set is the most frequently reported indicator set developed by the Australian Council on Healthcare Standards (ACHS) with 4,176 submissions from 324 healthcare organisations in 2024. The first edition of the user manual was published in 1991.

ACHS facilitates regular reviews to ensure clinical indicators are patient centred, concordant with standards of care and data is collectable at the organisation level. The Hospital-wide Clinical Indicator Working Party was convened in August 2024 to review and update the version 13 of the indicator set.

Measures that were added in this revision include:

Readmissions within 7 days
Cardiopulmonary resuscitation administered in the presence of a do not resuscitate order
Documented goals of care
Time from admission to the operating theatre
Risk assessments for malnutrition and falls
Net promoter score for organisations

Indicators that have been discontinued include:

Appendicectomy with normal histology
Tonsillectomy with haemorrhage
Time to theatre for hip fracture
Death without a resuscitation plan

Please see Table 1 for a summary of the changes and the user manual for further information and rationale.

The revised hospital-wide clinical indicator set, and user manual version 14 was endorsed by the Royal Australian College of Medical Administrators (RACMA) and is available for data collection commencing July 2026 and reporting in the 2nd Half 2026 dataset. We hope that you find these clinical indicators useful for improving safety and quality in your healthcare organisation. Please contact the Performance and Outcomes Service at pos@achs.org.au if you have any questions.

Table 1: Summary of changes to the Hospital-wide clinical indicator set

Version 13	Outcome	Version 14
HOSW Area One: Hospital readmissions
CI 1.1 Unplanned readmissions within 28 days	Retained	CI 1.1 Unplanned readmissions within 28 days
	New	CI 1.2 Unplanned readmissions within 7 days
HOSW Area Two: Return to the operating theatre
CI 2.1 Unplanned return to the operating room during the same admission	Retained	CI 2.1 Unplanned return to the operating theatre during the same admission
HOSW Area Three: Pressure injuries
CI 3.1 Inpatients who develop ≥1 pressure injuries	Retained	CI 3.1 Inpatients who develop ≥1 pressure injuries
HOSW Area Four: Inpatient falls
CI 4.1 Inpatient falls	Clarified	CI 4.1 Patient falls
CI 4.2 Inpatient falls resulting in fracture or closed head injury	Clarified	CI 4.2 Patient falls resulting in fracture or closed head injury
HOSW Area Five: Patient deaths
CI 5.1 Patient deaths addressed within a clinical audit process	Clarified	CI 5.1 Patient deaths reviewed within a clinical audit process
CI 5.2 Deaths in adult patients who do not have a NFR order	Updated	See CI 8.5
HOSW Area Six: Blood transfusion
CI 6.1 Significant adverse blood transfusion events	Retained	CI 6.1 Significant transfusion-related adverse events
CI 6.2 Transfusion episodes where informed patient consent was not documented	Clarified	CI 6.2 Blood transfusion where informed patient consent was not documented
CI 6.3 RBC transfusion where Hb reading is ≥100 g/L	Retained	CI 6.3 RBC transfusion where Hb reading is ≥100 g/L
HOSW Area Seven: Thromboprophylaxis
CI 7.1 VTE risk assessment	Moved	See CI 10.2
HOSW Area Eight: Goals of care
	New	CI 7.1 Clinical goals of care
HOSW Area Nine: Minimum standards for rapid response system (RRS) calls
CI 8.1 Rapid response system calls to adult patients	Removed
	Moved	CI 8.1 Rapid response system attendances within 5 minutes
CI 8.2 Rapid response system calls to adult patients within 24 hours of admission	Updated	CI 8.2 Multiple rapid response system calls to adult patients within 24 hours
CI 8.3 Adult patients experiencing cardiopulmonary arrest	Updated	See CI 8.4
	New	CI 8.3 Rapid response calls in which the patient needs high level care
CI 8.4 Rapid response system attendances within 5 minutes	Retained	See CI 8.1
	New	CI 8.5 Adult patients receiving CPR who have a known DNR order
HOSW Area Ten: Surgery
CI 9.1 Pre-operative acute appendicitis - normal histology	Removed
	New	CI 9.1 Time to operating theatre
CI 9.2 Laparoscopic cholecystectomy - bile duct injury requiring operative 45intervention	Retained	CI 9.2 Laparoscopic cholecystectomy – bile duct injury requiring operative intervention
CI 9.3 Tonsillectomy - significant reactionary haemorrhage	Removed
CI 9.4 Hip fracture care	Removed
HOSW Area Eleven: Risk assessment
CI 10.1 Frailty assessment	Retained	CI 10.1 Frailty assessment
	Retained	CI 10.2 VTE Risk Assessment
	New	CI 10.3 Falls risk
	New	CI 10.4 Malnutrition risk assessment
HOSW Area Twelve: Patient Experience
	New	CI 11.1 Net promoter score (NPS)