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!
This week, we hear from the lead of the CDI Team at Northern Health in Victoria Mary Kouvas. Hear how Mary was destined to be a CDS, and her success story with the "Phantom" clinician!
Tell us about your current role.
I am the Clinical Documentation Integrity Coordinator. I lead the CDI Team.
What is your career background, and how has that contributed to your ability to work as a CDS?
I completed my studies in Health Information Management in 1993 at Lincoln School of Health Sciences/La Trobe University and continued on with an Honours year. My paper focused on the curriculum of Medicine at universities and why clinical documentation and ABF were not part of it. Unfortunately I never completed the paper, but always had a burning desire to improve the way medical students/interns are trained in terms of clinical documentation. I worked in various roles as a HIM but always had a passion in coding and Casemix. I was exposed to Casemix funding early in my career as block funding was phased out and was able to work closely with clinicians during the retrospective documentation query process. Working with clinicians straight out of uni gave me an opportunity to mature and gain confidence in speaking with all levels of staff. I understand both the coder’s and clinician’s needs and therefore am able to bridge that gap. Sometimes it’s not an issue with the clinician’s documentation but an issue with the classification itself, so being able to send queries to the Victorian Coding Committee or send public submissions to IHPA to improve the classification has always been something I have done as a Coding Auditor/Educator. This experience has contributed to my ability to work as a CDS and lead the CDI team. I am not one to sit back and accept the current state. I like to improve processes where I can.
What made you apply for a CDS role?
I was quite fortunate to voice my opinion on our health service’s next steps in improving documentation, data reporting and funding. It was always an important activity, but it was performed retrospectively. With the need for more real-time data, I asked whether we could implement a CDI Program and the answer from our CFO at the time was “yes”. I had attended a few conferences and heard more and more about CDI and thought that this was something I could do and something I am very passionate about.
What does your typical day look like?
I always start my day with a strong flat white and check emails. These emails sometimes dictate how my day will look. I will then check a list of episodes I wish to review on the wards. Each of our CDSs has a portfolio and I have a mixed bag at the moment. I will review episodes where there is a gap in knowledge from the CDSs. My background as a HIM means that I have experience and knowledge in all specialties our hospital offers, including maternity and paediatrics. During reviews on the ward (we still have paper records but are moving towards an EMR) I may write a few documentation queries, I may speak with the interns and Registrars or nurses and NUMs. After lunch I may analyse previous month’s work. This happens once the episodes have been coded and I can compare DRGs and see whether the documentation query was answered and whether it impacted on the DRG. I may even correct the coding if that is required. I may also update documentation posters and presentations to deliver in the future. We are also developing our own in-house database/dashboard, so I may spend time testing the system. I also enjoy writing algorithms to use in dashboards and reports. Sending queries to VICC and IHPA may also be on my list as well as meetings.
What was the moment when CDI really “clicked” for you?
CDI clicked immediately for me early on in my career as a Coding Auditor/Educator. I was always pro-active when it came to improving clinical documentation. Whether it was through form design or contacting clinicians to answer documentation queries with me rather than sending them an email. In my previous roles, I was limited with clinical documentation improvement activities, so when this actual role of a CDS was introduced to Australia, I was excited to be given a designated role to perform all those clinical documentation activities whilst still having a hand in coding.
How would you describe your personal CDI philosophy?
Believe that what you are doing has a great purpose. Good clinical documentation improves patient care and outcomes and ensures hospitals are funded appropriately. When you have to sell that to clinicians, then my job is easy. I’m not trying to sell ice to the Eskimos, so to speak.
What is the biggest challenge you have faced as a CDS?
Bureaucracy.
What is the most memorable “win” you’ve had?
Lucky for me, there have been many wins. Hearing back from a particular Head of Unit who I had named the “phantom” as he was well known, but never seen, is one. We finally caught up to discuss good documentation tips in his specialty and it was a successful meeting. Seeing “bacterial pneumonia” or the use of “due to” or “secondary to” in our documentation is also a massive win! Makes me smile every time.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
You just didn’t know it at the time, but there was a specific job role for me in the future.
Favourite DRG?
E62 Respiratory Infections and Inflammations, I love looking out for HFNP or HFT given for greater than 24 hours.
Favourite additional diagnosis?
At the moment it is M62.50 Deconditioning. I love it when it pops up in our documentation rather than functional decline.
What are you excited about in the future of your role?
I’m excited to see the CDI program grow. I am excited to continue promoting the value in having a CDI program and hope to get a regular spot on various specialty meetings. The start of each year is exciting as I have the opportunity to speak with the new interns and shape their future in clinical documentation.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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