In CDS Snapshot, we're profiling CDSs from across Australia and ICD-10-AM countries. We'll get to hear how they got into the role, their triumphs, and challenges they've faced. CDSs contribute enormously to patient safety, quality of care, health service sustainability, and CDI as a whole, and we want them front and centre!
In our first ever instalment, we’re talking to Annette Horton from Central Queensland Health. Annette is a Level 1 Certified CDS.
Tell us about your current role.
Nurse Manager Informatics – the role is a dual role as IT Systems Administrator for Nursing Rostering Patient Acuity system as well as Coordinator of Clinical Documentation Improvement Program. As a certified CDS my role also includes concurrent reviews, staff training and education, development of resources, clinical policy and clinical form reviews, and being a member of the organisation wide Standard 6 Communicating for Safety Committee.
What is your career background, and how has that contributed to your ability to work as a CDS?
My background is in rehabilitation nursing. I was NUM of Rehabilitation for 14 years prior to taking on this role. In the NUM role I polished my leadership, project management and problem-solving skills. I also had a really good knowledge and understanding of the ABF model, SNAP, DRGs and performance monitoring and reporting. This knowledge and these skills are all transferable into the CDS role.
What made you apply for a CDS role?
Actually it came from out of the blue. I was tapped on my shoulder by the Executive Director at the time. I was told to put some of my more routine tasks to the side and be the link between clinicians and clinical coders. At the time I had no idea what that entailed and so what followed was a very steep learning curve for me. I had 14 years’ experience as a NUM in Rehabilitation and so was very familiar with SNAP, DRGs, inlier, outlier, ABF. What I didn’t know was how clinical documentation influenced capturing of the acuity/complexity of patients.
What does your typical day look like?
I have no typical day as such. Each Monday I have a catch up with my CDS team to look at what our week looks like, what training is being delivered and by who. We include a brainstorm session if a particular issue is raised by one of the team as it always good to hear different perspectives and from different lenses. I will spend 1-2 hours actioning IT Support requests in the am and again in the afternoon. I will review a couple of clinical policies and provide feedback to policy custodians. I may review a clinical form and provide feedback. I might spend a couple hours on a special project such as our Anaesthetics project cleaning the data, inserting pivot tables, creating visualisations and doing some data analysis. I might retrospectively review some charts with Pressure Injuries HACs and follow these up with clinicians or clinical coding. I might spend some time with one of the medical teams who are looking to improve their performance with Discharge Summary compliance. That might be looking through a Lean lens at the workflow identifying and minimising the challenges and optimising the opportunities. It could include delivering clinical documentation improvement education in medical orientation.
What was the moment when CDI really “clicked” for you?
For me it was when I developed our first annual performance report on the CDI program. Having the opportunity to look back over all the projects we led and were involved in, the number of reviews and training sessions we provided demonstrating the impact we had on clinicians as well as the organisation.
How would you describe your personal CDI philosophy?
My primary role is providing advice, support and guidance to clinicians keeping the message short and simple.
What is the biggest challenge you have faced as a CDS?
Trying to capture activity, performance and impact of the CDS role in a way that executive understand, appreciate and value.
What is the most memorable “win” you’ve had?
A couple of things. When I finally received formal approval and sign off of permanency of the CDI program and CDS positions. The other was when I managed to get Board approval for inclusion of a Clinical Documentation generic statement to be added at the top of the clinical policy template. This reinforces with clinicians and the organisation the importance Clinical Documentation has in clinical practice and the link to patient safety.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
Wow that’s interesting. I’m not sure I would think the CDS role was something I would be able to do, that I would have the skills and knowledge to do it well. I would have had lots of questions about the journey getting there and if I felt valued. You can never underestimate an employee’s sense of what they do is of value and of being valued.
E62B Respiratory Infections and Inflammations. There is usually good opportunity for increased specificity and associated additional diagnoses.
Favourite additional diagnosis?
Respiratory Failure Type 1 & 2 as well as any comorbidities or conditions impacting on care planning and management of the patient such as Obesity. Quite often this is either not documented well and/or linked to the comorbidity and therefore not captured in clinical coding.
What are you excited about in the future of your role?
What excites me is that this role is developing. What excites me is where I and my team can take the CDS role and program. What excites me is how we can assist, develop and support these roles/programs in ours and other organisations.
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