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 last CDS Snapshot of 2021, we’re back across the pond to New Zealand. Vinod Sati is a CDS in Middlemore Hospital, Auckland. Hear about his big dreams for CDI in NZ!
Tell us about your current role.
I'm presently working as a Clinical Documentation Specialist - mainly focusing on General Surgery and Plastic Surgery. My role involves engaging with clinicians and providing real-time feedback on clinical documentation. Part of my role is to concurrently review the clinical documentation to ensure that it is complete and reflects the clinical truth. I continuously provide education to the clinicians on the importance of quality clinical documentation.
What is your career background, and how has that contributed to your ability to work as a CDS?
Being a qualified Physiotherapist and having worked in both private and public health sector for many years, I have developed huge interest in Clinical Quality Improvement initiatives. I have worked the majority of my career in clinical Auditing and have acquired many skills and knowledge including Clinical Coding and health informatics, which has built my pathway to be a CDS.
What made you apply for a CDS role?
Having worked as a Clinical Auditor on various quality improvement programmes, I was looking for an opportunity to work proactively with the clinicians, so I can educate them on the importance of accurate clinical documentation. This role was advertised in the Middlemore Hospital and I realised that the job description was exactly the next step I was looking for. Ever since I was appointed for this role, the excitement and challenges of this role have become a career highlight for me.
What does your typical day look like?
Everyday is a different day in this role. Some days are packed with meetings, staff education sessions and presentations. However, most days are spent doing ward rounds, reviewing charts and liaising with clinical staff.
I start my day by perusing new admissions and filtering them as per our parameters. I go on ward rounds periodically and review the patient charts to ensure that the treatment plan is linked to the diagnoses. If not, I raise queries with the clinicians in real-time to ensure the diagnostic terms are noted so the clinical coders can capture accurate data of the episode of care.
An important aspect of the role is relationship building which involves me to meet executive team members, project team as well as senior clinicians time to time. I also maintain regular catch ups with Coding Managers and Health Informatics Managers. I also develop education material and give presentations to the new medical officers on each rotation, to ensure the key message is consistent from the get-go.
Another element of my role is to analyse the monthly data and prepare report for the executive team and senior clinicians, so the effectiveness of the CDI programme can be seen.
What was the moment when CDI really “clicked” for you?
In the initial stages of CDI program, I have seen resistance from the stakeholders involved, as is likely in any change curve. When I managed to provide the clinicians with data showing increased complexity of their patients and greater inflow of revenue to the organisation, I was able to change their perspective and got huge engagement from them – that was the moment it clicked for me.
How would you describe your personal CDI philosophy?
My personal view is that a CDS should focus on instrumenting behaviour change of the clinicians. Once behaviour change is achieved, we will automatically see increased quality, complete documentation and complexity being reflected in notes. This is a journey where we have to work collaboratively with the clinicians.
What is the biggest challenge you have faced as a CDS?
Being a new staff member to the hospital itself was a challenge to begin with. I feel the struggle has been changing the mindset of the clinicians that the CDI programme is about improving the clinical documentation to achieve the quality of the data and patient safety and not just about increasing revenue. However, the efforts have been somewhat fruitful, and we have started to see a gradual shift in their perspective through ongoing education and awareness.
What is the most memorable “win” you’ve had?
Although this programme is still quite a new concept to my hospital, I still feel like I have been accepted by the clinicians as a part of their team and that this programme is getting a bit of recognition. In my theory the small wins like seeing treatment plan linked to the diagnoses and improved data, amount to a huge success.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
The 10 year ago me would be surprised to see the impact of clinical documentation on the patients journey and safety. It would seem like a huge challenge that we endeavour to change long term behaviour and habits.
Favourite DRG?
G02B – Major small and large bowel procedures – where there is always an opportunity to find additional diagnosis like adhesions, post op complication i.e. wound infection and Ileus.
Favourite additional diagnosis?
Hypokalaemia – it is very interesting to see the number of times it is not documented as a diagnosis, while it contributes hugely to the complexity level of the DRG split.
What are you excited about in the future of your role?
CDS role is an emerging role in NZ. Middlemore hospital is only the second hospital in NZ to have initiated this programme. I would like to see this programme become a norm and expand to the other areas of the hospital and rest of the country.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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.