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 the latest edition we’re talking to Susan Mills, the District CDS for the Northern NSW Local Health District. Hear from one of the more experienced CDSs in Australia, and her incredible story driving documentation improvement across 8 hospitals!
Tell us about your current role
I am the District Clinical Documentation Specialist at NNSWLHD. I cover eight activity based funded sites across the LHD. I have been working as a CDS for six years and love it. I really enjoy the variety of the work. The role includes regular inpatient concurrent chart reviews and ward rounding with specialist teams, district wide education to doctors, nurses, allied health, midwives, and nurse practitioners, and working closely with clinical coders and health information managers. I have set up an electronic clinical documentation query platform that all our coders across the district use. It has back-end reporting for timely and efficient reporting to hospital executive. I enjoy working with different specialist groups to analyse and discuss their benchmarked data.
What is your career background, and how has that contributed to your ability to work as a CDS?
I am a Registered Nurse of 27 years. I worked as an Emergency Nurse Practitioner in the UK for many years, so I have a sound knowledge of anatomy and physiology, diagnostic and assessment skills, and clinical documentation. We were able to study alongside the undergraduate medical students in London. When I returned to Australia in 2008, I was a practice manager across two different primary health care settings. It was working in the private sector that really got me interested in how healthcare was funded and costed. Leading these centres through multiple accreditation cycles piqued my interest in quality and safety principals and clinical governance in patient care. I sat on various clinical councils and clinical governance committees. When the Job came up at NNSWLHD for a Clinical Documentation Specialist, I jumped at the chance.
What made you apply for a CDS role?
I really liked the variety of skills required for the job. I had a strong clinical background as an independent practitioner and experience in the private sector managing a health care facility. The impact of this role on quality and safety of care through clinical documentation was a drawcard.
I liked the mix of data analysis and audit with ‘on the ground’ engagement on wards and collaborating with clinicians across all disciplines.
The opportunity to analyse data to inform or question models of care within a service was also very appealing.
What does your typical day look like?
If I am on a 10–12-week block ward rounding with a speciality I will start on the ward with the team. This can take anywhere from one hour to four hours. Where appropriate I also use this as an opportunity for education to the clinicians within the team on clinical documentation principals. Following rounds, I will update my diagnosis spreadsheet for tracking and feedback. I respond to emails from various clinician’s, prepare for upcoming education sessions, attend committee meetings, review inpatient charts for the next day rounds, develop education material and analyse DRG data for different speciality groups across the LHD. I monitor our documentation query portal and assist coders with ethical documentation queries. I regularly report to hospital executive the query differentials.
What was the moment CDI really “clicked” for you?
CDI really clicked when I moved from consistent retrospective documentation audits to concurrent ward rounding. I was having an impact on the safety and quality of care of patients in real time. It was more meaningful to the clinician’s as they could better understand the CDS role and the direct impact working together could have on patient care. While rounding I was approached by a Registrar from another team to join them. This was a pivotal moment.
How would you describe your personal CDI philosophy?
Work with – not against. Flexibility with clinicians is paramount.
What is the biggest challenge you have faced as a CDS?
The biggest challenge so far has been trying to spread myself across so many hospitals. I have had such positive engagement with all clinicians, and everyone is keen to do their best in this space.
What is the most memorable “win” you’ve had?
When I presented the fiscal year results of documentation queries and concurrent ward rounding to hospital executive, they approved another CDS position for the LHD!
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
10 years ago, I would say, what is a CDS?! Why would we need a position like that? As clinician’s we were not taught to document with the specificity that is required in our system today. When you read clinical documentation that uses diagnostic statements, is specific and establishes casual links, the clinical picture of the patient is undeniable. It is so important for patient safety and quality of care.
Favourite DRG?
G02B – the potential to move the DRG to an A split through capture of an additional diagnosis is extremely rewarding.
Favourite additional diagnosis?
D62 Acute blood loss anaemia. I am constantly educating on anaemia diagnoses. It is often missed in the record.
What are you excited about in the future of your role?
It excites me that this role is new and emerging in Australia. It excites me that as a CDS for the last 6 years, my insights and knowledge can help shape the landscape for the future and success of the CDS role.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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