P0598 - Inpatient vs Observation...Improving Status Designation on Admission

The proper assignment of a patient's status on admission is not intuitive and is seldom taught to trainees or faculty, despite significant hospital revenue implications. Discussions at hospitalist division meetings and compliance reviews of bills revealed significant lost revenue from inappropriate assignments of admission status. We partnered with Utilization Management (UM) and a Clinical Documentation Integrity (CDI) specialist in a quality improvement project to improve status assignment on admission. We aimed to decrease the number of patients meeting inpatient criteria who are assigned observation status from a baseline of 27% to 15% in 19 months.
The context is a 216 bed children's hospital with 12 hospitalist faculty and 34 pediatric residents. The study population was any patient admitted to the medical ward under the hospitalist service with a status of "observation". We chose the proportion of patients who met inpatient criteria (according to UM review) among all patients coded as observation as our outcome metric. Interventions included a lecture series to house staff and hospitalist faculty covering the reasoning behind status designation, institutional definitions, and inpatient criteria for common diagnoses. Project leaders created a booklet summarizing this information and distributed it to resident work areas and the hospitalist office. Smart phrases with specific inpatient criteria for several common diagnoses were created in our EMR and distributed to providers. Ten months of baseline and 15 months of intervention data were plotted on a statistical process control chart (p-chart). Centerlines were shifted when special cause variation was met.
There were 795 pre-intervention and 1302 post-intervention observation stays. Twenty seven percent of the pre-intervention study population had an incorrect assignment of observation status. Special cause variation was present in February 2019 with a mean of 16.9%. Special cause variation was again seen in October 2019 with a new centerline of 11.7%.
Proper assignment of status on admitted patients is crucial to ensuring optimal hospital reimbursement. By partnering with UM and CDI we met our goal of decreasing the inappropriate assignment of observation status to patients meeting inpatient criteria to less than 15% using easy to replicate quality improvement methodologies. Future direction could include measurement of sustained improvement as well as analyzing financial impacts on the hospital.