November 28, 2023 | Net Health

7 min read

How HAPI Management Can Make or Break Your Bottom Line

Five issues hospital teams must address to optimize their HAPI management program

For busy hospital staff, caring for patients with pressure injuries (PIs) is difficult, complex, and often frustrating. Within a hospital setting, PIs are defined by the acronym HAPI, which stands for Hospital Acquired Pressure Injuries. The Centers for Medicare and Medicaid Services (CMS) has declared HAPIs “never events” and outlined a range of penalties and procedures to help lower their occurrence. In this post, you’ll gain an understanding of 5 key issues to explore in your hospital setting to build a robust and effective HAPI management program:

#1: Cost and impact of HAPIs on hospitals

The cost of providing care to patients with HAPIs is high and continues to grow. Here are the facts. HAPIs:

  • Affect a significant number of patients. Between 5% to 15% of hospital patients acquire a HAPI.1
  • Are costly. The U.S. spends more than $26.8 billion on caring for patients with HAPIs.2 The average HAPI costs hospitals up to $70,000 per case3.
  • The cost of individual patient care for severe PIs ranges from $21,000 to more than $151,000. CMS estimates that PIs add more than $43,000 in costs to a hospital stay.4

Yet another reason for hospitals to address HAPIs is that they are the second most common hospital lawsuit claim after wrongful death, leading to 60,000 patient deaths each year.6 All told, more than 17,000 lawsuits arise due to PIs7 annually at an average settlement of $250,000.5 And let’s never forget the human toll. It’s estimated that 2.5 million8 people will suffer a PI this year, far too many considering the solutions now available.

On average, hospitals must pay between $5,900-$14,840 for a Stage 3 and between $18,730-$21,410 for a Stage 4 (Cost to Treat).5

#2: Factors contributing to HAPIs today

A variety of factors lead to HAPIs. A good source for a more in-depth exploration are the 2019 International Clinical Practice Guidelines, developed in collaboration with the National Pressure Injury Advisory Panel (NPIAP).9 According to clinicians, both physiological (intrinsic) and non-physiological (extrinsic) risk factors influence a patient’s risk of acquiring a PI. These include diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension.10 While some pressure injuries are unavoidable11, a troubling trend is the increase in HAPIs. The Agency for Healthcare Research and Quality (AHRQ) shows that the national rate of pressure injuries rose by 6% from 2014 to 2017, rising from 21.7 injuries per
1,000 discharges in 2014 to 23 per 1,000 discharges in 2017.12

#3: Penalties from federal agencies and payers

In 2006, the Bush Administration issued regulations, which, among other things, enable CMS to penalize hospitals for conditions “that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a diagnostic relations group (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.”

CMS considers Stage 3 (full-thickness skin loss) or Stage 4 (full-thickness skin loss and tissue loss) PIs “never events” and will not reimburse hospitals for the cost of care.14 All U.S. hospitals with a total score in the bottom quarter face reduced payments of 1% of the total hospital claims to CMS. Nearly 80% of hospitals are hit with a HAPI penalty.15 With the onset of value-based initiatives, hospitals also face reductions in reimbursement from payers. Additionally, low scores impact Quality and Star ratings, as well as the standing of the facility within its community.

A typical 300-bed hospital could lose more than $10 million in unreimbursed costs due to excess HAPI penalties.3

Some issues that hospitals must address to help optimize their HAPI management programs are cost, risk factors contributing to HAPIs, federal agency and payer penalties, and existing and emerging technologies.

#4: Existing and emerging technologies to help HAPI management

Recognizing the need to combat HAPIs and with a commitment to better serve patients, hospitals have embarked on numerous Pressure Injury Prevention (PIP) initiatives. Components of effective programs include greater use of technology, targeted education, mentors, and the adoption of evidence-based protocols. Many of these HAPI management programs have helped reduce HAPIs by 50% or more, clearly proving their value.16 The evolution of existing technologies – specifically specialty electronic health records (EHR) such as Net Health® Wound Care, which integrate clinical, financial, and regulatory tools —are also making a difference.

Two of the more significant advancements of the past few years have been the introduction of digital imaging and analytics for decision making. Advanced digital imaging apps available on smartphones and tablets have enabled clinicians to standardize wound measurement, identify wound healing rates, and provide more rapid and appropriate interventions. Tissue Analytics is one of the early pioneers in the field of wound care imaging.

Hospitals using Tissue Analytics have seen a 90% reduction in measurement errors, with error rates coming in at less than 4%, compared to 44% using hand and ruler measurements.

In terms of analytics, innovations such as Net Health® Clinical Analytics for Wound Care, utilize predictive analytics models that help clinicians understand a patient’s unique risk and more accurately predict wound healing outcomes. The information provided enables faster and more accurate interventions, helping to ensure better outcomes.

#5: ROI: Making a case for stronger HAPI management programs

With the uncertainty in the hospital marketplace today, it’s important to provide proof of the value and ROI for any initiative. Targeted programs that address HAPIs are rapidly demonstrating their ability to achieve the following goals:

  • Manage costs
  • Improve outcomes and patient quality of life
  • Reduce penalties and risk
  • Integrate seamlessly into workflow
  • Lessen time clinicians spend on administrative tasks

Building stronger HAPI management programs begins with making a strong and supportable case for its ROI, which encompasses staff efficiency and productivity, reduced cost of care, lower readmission rates, reductions in penalties, and optimal reimbursement.

Potential penalties due to health system-wide-acquired pressure injuries17

Using its advanced analytics and team of data researchers, Net Health has developed a number of scenarios outlining the cost savings that could be achieved by a typical hospital. Here’s one example: The data below shows potential penalties for a hypothetical mid-sized regional hospital system, with facilities with a range of Stage II, Stage III, and Unstageable Pressure Injuries (PSI-3 HAPIs) rates over 12 months. The hospital system has 1,500 total beds. (Note: PSI-3 HAPIs are measured based on the number of pressure injuries per 1,000 discharges. Based on 2020 data from Net Health covering more than 9,100 short-term acute care hospitals, the average PSI-3 HAPI rate is 0.216.) CMS will not reimburse hospitals for never events, resulting in penalties for non-compensated care. Using standard industry data, we can extrapolate the following:

  • Discharges = 50,000 per year
  • Pressure Sores Rate = Varies
  • PSI-3 HAPIs = 50
  • After removing 25% to account for non-eligible discharges
  • Total Estimated Never Events (PSI-3 HAPIs) at $50,000 per HAPI = $1.7 M in non-compensated care. A conservative 50% reduction in HAPIs could save nearly $1M per year.

Never events and HAPIs

The National Quality Forum (NQF) states that never events are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” In 2007, CMS adopted a policy defined as “non-reimbursable serious hospital-acquired conditions” – to encourage hospitals to accelerate improvement in patient safety and quality. According to the Department of Health and Human Services, Office of Inspector General (OIG), “if a HAPI reaches Stage 3 (full-thickness skin loss) or Stage 4 (full thickness skin loss and tissue loss), it is a never event that is reported to CMS and that results in subsequent limited reimbursement.” (Levinson, 2010). Hospitals are also required to pay for any additional expenses related to the never event. This is a complex and critical issue for wound care providers. For additional information, check out these resources:

  1. Facility Never Events in Wound Care
  2. Quality Forum
  3. AHRQ Patient Safety Network
  4. Medical Quality Initiatives Patient Assessment


  1. N. Mondragon, P. Zito, Pressure Injury. StatPearls. Dec. 2021.
  2. WV Padula, BA Delarmente. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. June 2019.
  3. NA Vitale, DA Dzioba. Why investing in hospital-acquired pressure injury prevention technology makes financial sense. Healthcare Finance News. Feb. 2021.
  4. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed. AHRQ. Last reviewed 2017.
  5. Pressure Ulcer/Injury Coding Stages. QPR Pocket Guide. CMS.
  6. L. Spruce. Back to Basics: Preventing Perioperative Pressure Injuries,” AORN, Oct. 2017.
  7. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. AHRQ.
  8. Pressure Ulcers. AHRQ.
  9. International Clinical Practice Guideline. National Pressure Injury Advisory Panel.
  10. Pressure Ulcers: A Patient Safety Issue. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ. 2008.
  11. J. Pittman, T. Beeson, et. al. S Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable. Am J Crit Care. Sept.2019.
  12. National Scorecard on Hospital-Acquired Conditions. AHRQ.
  13. Tissue Analytics Analysis of Wound Care Data. Net Health Data. Available upon request.
  14. CMS Pocket Guide.
  15. Healthcare Finance News
  16. Hospital-Acquired Conditions (Present on Admission Indicator). CMS.
  17. Tissue Analytics Data. Available upon request.
Share this post

Subscribe and See More