Master patient index (MPI)

Purpose

To develop and implement master patient index in the hospital for proper patient identification, registration hence to maintain one authentic medical records

Policy Statement

Muhororo hospital shall ensure that all enrolled patients are given individual manual master patient index that linked to his/her medical records.

Definitions

Master patient index (MPI): Is a database that is maintained by a health care organization for the purpose of identifying a patient and their medical record.

Equipment

• Computers
• Registers
• Pens
• Cards

Procedures

1. Electronic and manual master patient index system is used in hospital.
2. Paper based index card is provided to each enrolled patients.
3. The index card is composed by the following elements:

1. Name of the hospital and address.
2. Patient demographic information( Names, age, gender, address, contact phone number)
3. Patient insurance information.
4. Date of first visit, date of admission, date of discharge
5. Given ID number of patient medical record.
6. Unit provided the services to the patient.

1. The same information on index card is written in the register and computer available at medical records and archiving unit.
2. The patients keep their own index cards.
3. The patients come back with their index card at each visit.
4. If the index card is lost, the patient will be provided another one with the same information of the first card.
5. The medical records and archiving department staffs manage master patient index.

Reference

1. AHIMA. "Fundamentals for Building a Master Patient Index/Enterprise Master Patient Index (Updated)." Journal of AHIMA (Updated September 2010).
2. Skurka,   Margaret. Health   Information   Management:      Principles   and Organization for Health Information Services. San Francisco, CA: Jossey Bass, 2003.
3. Policies and procedures sent by MoH December 2017

Purpose

The purpose of this policy is to provide the guidance regarding management of risks to support the achievement of Muhororo's objectives to minimize and or eliminate risks related to Clinical, operational, financial, physical and environmental risks, medicalegal, ethical and reputation risks.

Policy Statement

1. Muhororo District Hospital is responsible for establishing and overseeing the establishment, implementation and review of risk management process.
2. Muhororo District Hospital may delegate the responsibility of reviewing the effectiveness of the risk management process periodically and changes to the policy should be approved by the hospital leaders
3. The hospital ensures that risk management register is effectively completed to control the risks
4. The  hospital should ensures that all risks are identified accordingly

Definitions

• Risk: is defined as an effect of uncertainty on objectives. an effect is a deviation from the expected-positive and /or negative. It also can be defined as an anticipated event or action that has a chance of occurring, which may result in a negative Impact. Also can be defined as a situation involving exposure to danger.
• Risk management: a systematic process of coordinated activities to direct and control an organization regards to risks. Also it can be defined as a systematic process of identifying, analyzing and responding to anticipated future events that have the potential to generate unwanted effects
• Risk identification: process of finding, recognizing and describing risks
• Risk analysis: is defined as a process to comprehend the nature of the risk and to determine the level of the risks.
• Risk evaluation: the process of comparing the results of risk analysis with risk criteria to determine whether the risk and /or its magnitude is acceptable or tolerable
• Risk assessment: it is an overall process of risk identification, risk analysis and risk evaluation
• Risk classification: is the process of classifying risks into various categories.
• Risk Owner :  Person or entity with the accountability and authority to manage risk

Equipment/Forms/Material

• Risk report form;
• Risk register
• Risk assessment template form
• Aggregate scorecards form
• Risk profile forms

Procedures:

1. The process for identifying risk.

1. Comprehensive risks identification using a well-structured systematic process is critical because a potential risk not identified is excluded from further analysis. Identification should include all risks whether or not they are under the control of the hospital. Risks can be identified in a number of ways.
2. All identified risks should be updated in a risk register
3. Risk registers should be periodically reviewed to ensure pertinence of the risks listed and risks that would have ceased should be closed appropriately.
4. The Risks Management Steering committee should ensure that the risk register is reviewed and updated accordingly.

1. The process for analyzing risks: The risks will be assessed basing on five steps including:

• Hazard identification: Employer has a duty to assess the health and safety risks faced by his worker.
• Decide who may be harmed and how:   During risk assessment there is a need to identify who is at risk
• Assess the risks and take action: the employer must consider how likely it is that each hazard could cause harm
• Make a record of the findings:  the employer with other staff are required to record in writing the main findings of the risk assessment.
• Review the risk assessment: the risk assessment must be kept under review in order to ensure that agrees safe working practices continue to be applied and take account of any new working practices.

1. The roles and responsibilities of those identified to implement the risk management plan

• Risk treatment/action plan involves identifying the likelihood of risk, feasibility and severity of the risk
• Action plans need to be time bound and responsibility driven to facilitate future status monitoring
• Action plan regarding to risk management will be monitored every six months this means it will be evaluated twice a year.
• Every employee of Kabaya district hospital has a responsibility of identifying risks and report accordingly.
• Once the risk happens, the appropriate staff need to report accordingly to his/her direct supervisor for further management.
• Once the patients or visitors mention unidentified risks, the concerned risk management committee will immediately update the risk management register.

1. The processes for tracking and reporting risks

• A risk review should involve re-examination of all risks recorded in the risk register and risk profile to ensure that the current assessments remain valid. Review also should aim at assessing progress of risk treatment action plans.
• Risk reviews should form part of agenda for every Risks management steering committee meeting.
• The risks register should be reviewed, assessed and updated on a periodic basis.

1. The processes for reviewing the risks management plan and risk register 

• Carry out responsibilities as assigned by the hospital leadership
• Review and update risk management policy
• Monitoring and reviewing of the risk management activities as approved by the hospital leadership
• Review and approve the risk management report for approval of the hospital leadership
• Ensuring that appropriate activities of risk management are in place 
• Ensure implementation of risk mitigation plans 
• Periodic updating of Kabaya District hospital’s risk management program for assessing, monitoring and mitigating the risks

Appendix: 1 RISK REGISTER

HOSPITAL NAME:..........................................................

PROJECT MANAGER:.....................................................

DATE:.................../....................../.......................

REFERENCES

1. How to Implement a Formal Occupational Health and Safety Program accessible at http://www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/howtoimplement_ohs.pdf

1. Guide to developing your workplace injury and illness prevention program, State of California CS-1 revised August 2005 - Cal/OSHA Consultation Service
2. Brainstorming
3. Ministry of Education-Policy and Procedures on Risk Management 2021