Words Matter – Outside of The Hospital Setting and Within
By Juliet Ugarte Hopkins, MD, ACPA-C
It’s often said that “words matter.” For those who work with patients and their families, the implications of this are clear. But have you ever thought about how word choice might affect the way others on the hospital care team think about your direction?
What do you say when a patient is hospitalized in Inpatient status, but it’s not supported by the patient’s medical condition or plan of care? How about the reverse - when a patient was initially hospitalized as Outpatient but now it’s clear that change to Inpatient is appropriate? Does your physician advisor recommend “downgrading” the first case and pursuing a Condition Code 44? Or, does a utilization manager call the attending physician for a new order to “upgrade” the second case to Inpatient status?
Patient status is a tricky enough concept for people to understand without assigning it positive or negative connotations. True, in many instances – but not all! – there is more reimbursement to the hospital for an Inpatient claim compared to an Outpatient claim with Observation services. However, this does not legitimize equating Inpatient with an “upgrade” in patient status compared to an Observation case. The status is the status wherever it falls with whatever criteria or rule the payor follows. There shouldn’t be any concerted effort on the staff’s behalf to work toward “upgrading” as many patients as possible. If change to Inpatient is appropriate, then fine. Work to obtain the Inpatient order from the clinician, but eliminate the term “upgrade.”
Similarly, changing a patient from Inpatient to Outpatient with or without Observation services isn’t a “downgrade.” It’s an appropriate change in status when we discover the initial determination was faulty. Also, beyond the insinuated messaging about status to our case and utilization management staff, nurses, and physicians, can you imagine the unease a patient might feel when overhearing this kind of comment? Increasingly, I’m seeing hospitals elect to carry out their daily unit rounds out in the open at the nurses’ station as multitudes of patients and their family members stream by. How would you feel if you didn’t know what your grandma’s nurse meant by, “I’ll ask the doctor to downgrade her, today”? If you think the COW and CABG debacles from the past were a shame, just wait until this bombshell of misunderstanding hits your local news outlets!
Anyone who’s worked with me knows my bug-a-boo involving the term “admission” when referring to any patient who’s been hospitalized. If I had a quarter for everyone who’s rolled their eyes when I made the distinction, I would be well beyond ownership of a Bitcoin by now! But, I WILL die on this hill, and I maintain it’s incredibly important not to interchange the words, especially when speaking to folks from multiple different disciplines and departments within the hospital. Yes, the physicians and APPs who accept new patients from the Emergency Department are referred to as “admitters” and I’m not suggesting they be called “hospitalizers.” But, too many equate an “admission” with “patient in Inpatient status” that I truly think assuming they don’t is a huge mistake.
Take for example, a hospital which had regulations referring to the need for discharge summaries. Creation of a discharge summary by the attending physician was noted to be required within two weeks of discharge, “for all patients discharged following an admission to the hospital.” The hospital’s new physician advisor was confounded after a few months as it became seemingly clear there was a rash of non-compliance with this rule. Multiple cases reviewed as part of a workgroup he was part of had no discharge summaries. When he brought it up to the hospital’s vice president of medical affairs, he was astounded at the lack of concern. “Patients discharging as Outpatient in a Bed or Observation don’t count as admissions,” she said. “Only patients in Inpatient status require discharge summaries.”
Being a stickler for detail like any good physician advisor should be, this situation ultimately led to identification that nowhere in the hospital regulations did it specify “admission” equaled “patient discharged in Inpatient status” even though this was understood to be the case. As such, it could have been construed that “admission” meant any hospitalized patient and the organization would have some explaining to do if auditors came knocking. The regulations were ultimately updates to specify a discharge summary was required for, “all patients discharged following hospitalization.”
“Admission” vs. “hospitalization” terminology can also make an enormous difference when collecting and assessing specific metrics within your hospital. Interested in addressing the average length of stay of patients hospitalized with a primary diagnosis of COPD exacerbation? The number you initially receive might be skewed if patients hospitalized in Outpatient with Observation services are not included in the mix. Readmissions classically involve patients re-hospitalized in Inpatient status who have an index or, initial hospitalization which ALSO involved Inpatient status assignment. But, from a patient care perspective, is this really the right way to look at it? Should we care any less about a patient who is re-hospitalized for Observation services or who a week before was hospitalized for Observation services?
As with essentially every other scenario in life, words matter. Sometimes, the words we use are so ingrained in the culture that we lose sight of how others might perceive them. Keep an ear out for these and other potentially misleading or misguided words and phrases and consider how a change in a turn of phrase might benefit your operations.