The CDS is the most important element in any clinical documentation improvement (CDI) program. CDI is a behavioural change process implementing scientific principles, with the core principle that binds everything together being reinforcement. It is the CDS who brings the reinforcement to the CDI process.
With that in mind, who is the most appropriate person to be a CDS?
The core competencies involved with the role
The CDI space in Australia is evolving rapidly, and there is a deficit of widespread knowledge about the core competencies of the CDS role.
Typically, a CDS comes to the role with previous healthcare experience – with either a nursing or Health Information Management (HIM) background.
The CDS role can be challenging at times. That is why selecting the right individual for this role is a critical step in a CDI program’s success.
There are three major questions to consider when considering a candidate for the role of the CDS:
Here is a look at each aspect in detail.
Your CDS needs to be high functioning from the project development and maintenance side, from going through patient records to maturely engaging with clinicians.
As such, the role lends itself to a more mature, resilient person with a lot of initiative and enthusiasm. A strong CDS should also have a positive upbeat disposition and a sharp eye for detail.
The CDS spends a lot of time analysing patient records looking for gaps or deficiencies in documentation, so the person needs to enjoy hunting for clues and uncovering these deficiencies. They should also have strong analytical skills.
It is helpful if the person has strong clinical acumen with experience in clinical documentation, so they can easily understand and interpret any results and treatments that don’t have an accompanying diagnosis.
The CDS will need to positively engage with doctors regularly. Giving senior clinicians feedback about their work isn’t an easy task for anyone – yet some personalities thrive on it. Ideally, aim to recruit your CDS from within your organisation as they have pre-existing relationships, respect, and trust.
If someone fits all three aspects and is keen to play a significant role in implementing organisational change for the better, they will thrive in the position.
Other essential skills
When considering the most appropriate person to be a CDS in your organisation, you also need to consider questions such as:
Importantly, the CDS role is autonomous – they are not doing regular medication rounds or working to a defined schedule. The role is fluid, requiring a lot of initiative in the day-to-day tasks.
As they are creating a behavioural change program across a hospital, the CDS needs high-order skills. It is not an ideal role for a new graduate or an introverted personality and is better suited to someone who has been working in hospital systems for many years.
The final word
Choosing the right CDS is a vital part of your CDI program’s success. Keep in mind that even the most well-suited candidate to the role needs to be trained properly so they are fully equipped with the knowledge and skills to develop the program and excel in the role.
At CDIA, we provide ongoing training and support for your CDS at every stage of your CDI program. Contact us to learn more about how we can help you select the ideal CDS for your hospital.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.