3 onboarding mistakes that frustrate trauma registrars (and lead to bad data)

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Trauma leaders increasingly recognize the vital role of registrars in trauma care. But unlike professionals in many fields, trauma registrars often receive limited formal training. Many new registrars still learn by exposure to the job. According to experts, this approach to registrar training creates serious problems.

“Registrars who are trained by ‘just doing the job’ do not learn the right way to do things,” said Sandra Strack-Arabian, CSTR, CAISS, trauma research and data quality manager at Tufts Medical Center in Boston. “Learning by exposure increases the risk of getting inconsistent and outright erroneous information. You end up with a confused and dissatisfied registrar — and really bad data.”

Recently, Strack-Arabian and other trauma registry experts discussed common registrar onboarding mistakes. They also talked about what trauma programs can do to create a strong onboarding process.

Mistake #1: Your training plan is “trial by fire”
The first misstep is throwing registrars into their job without enough introduction. “In some hospitals, new trauma registrars are just overwhelmed,” said Lisa Brown, CSTR, an adult/pediatric/burn trauma registrar with MedPartners HIM. “They are given too much responsibility too fast, and at the same time there is a lack of training and direction. That’s why many trauma programs see a big turnover in the registry. It’s because of discouragement and frustration.”

Brown advocates a gradual approach to registrar onboarding. “The best way to train someone who has no experience is to feed them a little bit of information at a time and let them become comfortable with doing each particular task before moving on,” she said. “If the new registrar gets overwhelmed, they will be out the door fast.”

At Tufts, Strack-Arabian has developed a structured onboarding plan for new registrars. Training proceeds methodically from basic information to advanced skills. New registrars receive a thorough introduction to registry concepts and tools before they begin abstracting cases.

“We start the registrar off with simple projects at first, so they can have some small successes,” Strack-Arabian said. “Then we move on to larger things.” Registrars typically take a full year to learn the job well, but structured onboarding provides a good foundation quickly. “After about 90 days, new hires start to feel comfortable in their skin.”

Mistake #2: You don’t show registrars “the big picture”
To do their job well, trauma registrars need to understand how data supports patient care and system improvement. Unfortunately, registrar onboarding often focuses narrowly on data entry.

“If a registrar does not know what is ultimately done with the data, it is just a bunch of numbers and words,” Brown said. For example, charts may show that an injured patient was held at a referring hospital for more than 6 hours. If the registrar does not understand the concept and goals of the trauma system, he or she will probably fail to flag the case for performance improvement. “On the other hand, if the registrar knows the goal of data collection, she or he will be more involved and proactive in looking for issues that need to be tracked and trended,” Brown said.

Understanding the goal of the registry is particularly important for new registrars who come from a coding background, according to Jacqueline Moses-Hardy, RHIA, CSTR, co-founder of Trauma Leadership Development Trainers, LLC. “Trauma registry rules are different from what they were taught as coders,” she said. “You have to switch their mindset from coding for reimbursement to coding for injuries and procedures.”

According to Strack-Arabian, the upcoming transition from ICD-9 to ICD-10 will make it even more important for registrars to have a strong understanding of the big picture. “In ICD-10, pick lists are huge, so it will be more important than ever for people to use their brains,” she said. “More and more, registrars will need to take the time to understand the injury and the care processes before they pick the right answer.”

Mistake #3: You don’t help registrars get out of their silo
While more people recognize the importance of a strong trauma registry, many trauma registrars are still isolated from their trauma team colleagues.

“In conversations with trauma registrars across the country, I find that many registrars say they don’t feel like they’re an integral part of the trauma team,” Strack-Arabian said. “For example, in many hospitals the registrars prepare data for the monthly staff meeting, but they don’t go to the meeting themselves.”

Integrating registrars into the trauma team should start at onboarding. “It is very important to expose the registrar to everyone in the trauma service by way of formal introductions,” Strack-Arabian said. “We also introduce registrars to key players such as the ED manager, the chief of emergency medicine, people in orthopedic surgery and neurosurgery, and hospital administrators — either before or soon after they begin their official duties. We want them to get the sense right away that ‘I’m part of this’ and feel comfortable within the service and the whole institution.”

According to Brown, registrars need to have direct access to the entire team. “In many hospitals, the trauma registrars go through the trauma program manager to communicate with other members of the team, such as surgeons,” she said. “That can be OK sometimes, but if the TPM is always the middleman it will not promote the discussions that are important for learning.”

Get the vision right
Ultimately, successful onboarding depends on how hospital and trauma program leaders view the role of the trauma registrar.

“Up until recently, the trauma registrar was often looked on as just a data entry person,” Strack-Arabian said. “Resources for Optimal Care of the Injured Patient, 2014 — the ‘Orange Book’ — did a great job of talking about the different responsibilities of the registrar, but then on page 110 it includes this statement: ‘It is important to acknowledge that high-quality data begin with high-quality data entry….’ That is tantamount to saying that surgery is about having good sewing skills.”

To get more out of the trauma registry, hospitals need to devote more resources to registrar onboarding, training and continuing development. “With the growing expectations for what registrars must produce, the trauma registrar role really should be looked at as a professional level position,” Strack-Arabian said. “Investing in the trauma registry means investing in the registrar.”

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