During a management meeting, Blair, Steven, and Jarrett discussed a serious problem with the master patient index (MPI) at Aubreyville Regional Hospital. Blair, Aubreyville’s HIM Director told the team that she had noticed a drastic increase in the requests to combine duplicate medical record numbers. Blair’s team is responsible for the actual merging of the duplicate numbers. Typically, HIM identifies the duplicates or another department locates them and contacts the HIM department. Blair had asked her team to keep a count of how many pairs are merged so the data can be trended daily, weekly, monthly, and yearly. After her last audit, Blair created a line graph to show the progress or decline of duplicate medical record number creation.

Steven, Patient Registration and Admitting Director at Aubreyville, worked closely with Blair to ensure he understood which of his team members were inadvertently creating the duplicate numbers during the registration process. Through this work, Steven was able to pinpoint which of his staff members was more error-prone than others. Jarrett, Information Services Director, was also a great resource because he provided reports that were generated out of the hospital information system (HIS).

After discussing the upward trend, the team decided that a root cause analysis should be performed to fully understand the impact of a MPI that contains numerous duplicates. The deep dive into the analysis would be a multi-faceted review that would take place over a week. Jarrett was tasked with generating daily reports to show potential duplicate creation. The report would contain the employee numbers so that Steven could drill down and aggregate the number of duplicates created by each of his registration staff members. If certain staff members continued to create multiple duplicates, Steven would know that additional training was needed. During the review period, Blair would also trend out the number of duplicates cleaned by her team. Through all of these efforts, the team could develop training and communication opportunities.

At the end of the review period, the team reviewed the results. They learned that a few registrars were creating nearly all of the duplicate errors. Steven determined that those staff members would be retrained and audited on a regular basis. Blair and Jarrett agreed to keep reporting available to provide Steven with information to track improvement. The team was satisfied that they had a good plan to follow going forward.

A few registrars made nearly all of the duplicate errors. Why did these registrars need to be retrained?

Why do Blair and the HIM team trend out the number of duplicates that they resolve?