Job

General Role Statement:

The Clinical Documentation Specialist (CDS) is responsible for facilitating the overall quality completeness and accuracy of clinician documentation in the patient health care record to support the delivery of high quality patient care, accreditation and adherence to quality standards, the clinical coding process and appropriate reimbursement.

ORGANISATIONAL OVERVIEW

Introduction

At Northern Health, we take care of the residents of Melbourne’s north, by providing a diverse range of health services, at Northern Hospital Epping, Broadmeadows Hospital, Craigieburn Centre and Bundoora Centre. We also collaborate with our partners to help expand the range of healthcare services offered to our culturally rich and diverse community.

Northern Health provides a vibrant, fast-paced workplace, with the busiest Emergency Department in Victoria. We are located in the rapidly growing northern suburbs, which is driving us to think innovatively about the needs of the population and what the health system of the future might need to look like to meet those needs.

As an organisation, we are shifting our focus from illness to putting a spotlight on supporting our community in ‘staying well’. In order to achieve this, we are developing strong relationships with other health service providers and the community across the region, to help us think differently about the future.

Northern Health provides a dynamic working environment, with a strong culture of teamwork, diversity, safety and respect.

Our Strategic Plan

Northern Health’s Strategic Plan for Northern Health includes the following elements -

Our Vision:
A healthier community, making a difference for every person every day.

Our Values:
• Safe – We provide safe, trusted care for our patients. We are inclusive, culturally safe, celebrating the diversity of our community.
• Kind – We treat everyone with kindness, respect and empathy.
• Together – We work together with our staff, patients, consumers and health system partners.

Our Priorities:

Northern Health has determined five strategic goals. Focussing on these goals will support us to achieve our vision and mission.

• A safe, positive patient experience
• A healthier community
• An innovative and sustainable future
• Enabled staff, empowered teams
• Engaged learners, inspired researchers

These priorities are inter-related in that success in one area is dependent on success in another. Detailed plans have been developed to support each of the priority areas.

All Northern Health employees will contribute to improving patient safety by being familiar with, and applying the National Safety and Quality Standards and criteria.

Safety, Quality and Clinical Governance at Northern Health

Northern Health is dedicated to providing the highest quality of care in the safest possible environment for every patient every time. We are focused on strengthening the safety and quality of care across the continuum, with a focus on saving lives, reducing harm and improving the patient experience.

Northern Health’s safety and quality improvement activities focus on delivering the Strategic Plan and Operational Business Plans, and are supported by the Northern Health Clinical Governance and Risk Frameworks, and the Northern Health Quality Improvement Methodology.

The Northern Health Quality Management System brings together the core elements that underpin how:
• Quality and Clinical Governance is determined.
• Quality services are delivered.
• Risk is managed.
• Audit – what matters is monitored.
• Our committees monitor performance of controls put in place to ensure safe patient care.


ROLE STATEMENT

As the Clinical Documentation Specialist, you are responsible for:
• Facilitation of the overall quality completeness and accuracy of clinician documentation in the patient health care record, to support the delivery of high quality patient care, and adherence to quality standards, the clinical coding process and appropriate reimbursement.

Key responsibilities
• Conduct concurrent review of the patient health care record to evaluate the clinical documentation and identify documentation gaps for action.
• To facilitate the appropriate review of clinical documentation at the point of care which reflects both care delivery and resource utilisation to support the appropriate reimbursement of services.
• Identify conflicting, incomplete or nonspecific documentation within the medical record and formulate clinician queries by requesting and obtaining additional documentation within the health care record as necessary.
• Collaborate and engage with clinical teams including doctors, nursing staff and allied health staff to help close the gaps in their clinical documentation.
• Deliver ongoing education regarding CDI to all clinical staff responsible for documenting in the health care record.
• Assist with the development of a Documentation Integrity Plan for the CDI Program.
• Complete CDI quality activities and audits as appropriate.
• Liaise closely with the coding team to ensure familiarisation with coding practices and activity based funding principles and compliance with Australian Coding Standards and Victorian advice.
• Ensure the delivery of timely and accurate key performance indicators in relation to CDI.
• Develop a close working relationship with key stakeholders to produce timely outcomes for our stakeholders.
• Support the Operations Manager Clinical & Casemix and Clinical Documentation Integrity Coordinator in implementing strategic initiatives by engaging with Executive Directors, Program Directors and Department Managers.
• Participate in projects (including cross functional projects) undertaken by the Health Information Services team, including matters relating to new legislation, Government directions, system changes and business improvement processes.
• Develop and maintain positive working relationships with internal and external stakeholders.
• Represent Health Information Services on designated internal forums and at external forums including monthly coding meetings and education sessions and Clinical Improvement Committees where required.

All employees:
Quality, Safety, Risk and Continuous Improvement
• Maintain an understanding of individual responsibility for patient safety, quality & risk and contribute to organisational quality and safety initiatives
• Follow organisational safety, quality & risk policies and guidelines
• Maintain a safe working environment for yourself, your colleagues and members of the public.
• Maintain an understanding of individual responsibility for patient safety, quality & risk as outlined in Northern Health Clinical Governance & Patient Experience – Trusted care procedure.
• Contribute to organisational quality and safety initiatives.
• Escalate concerns regarding safety, quality & risk to appropriate staff member, if unable to rectify yourself.
• Promote and participate in the evaluation and continuous improvement processes.
• Comply with principles of Patient Centred Care.
• Comply with Northern Health mandatory continuing professional development requirements.
• Comply with requirement of National Safety & Quality Health Service Standards and other relevant regulatory requirements.

KEY RESULT AREAS AND MAJOR RESPONSIBILITIES

Clinical performance
• Conduct on average 8-12 record reviews per day.
• Utilise and maintain monitoring tools to track the progress of the Clinical Documentation Integrity Program and identify opportunities to improve documentation review processes.
• Collect and analyse data and report on performance measures of Clinical Documentation.
• Promote awareness and monitor documentation quality practices across Northern Health.
• Create, foster and promote a high performing culture within Clinical Documentation Integrity team.
• Use benchmarking to identify potential improvement opportunities.
• Continuously evaluate system and process efficiency and improvement opportunities.

Organisation-Wide Contribution
• Lead relevant Northern Health systems, processes and service standards through:
o Meeting quality systems standards and procedures
o Seeking customer feedback to inform how we provide care
o Continuous system and process improvement
o Eliminating waste
• Be responsible for optimising budgeted and project resources through relevant activities including contribution to the Operational Business Plan and budget process.
• Demonstrate by example, adherence to and role modelling of the Northern Health values and Staff Code of Conduct.
• Excellent knowledge and ability to apply the National Safety and Quality Health Standards.


Diversity and Inclusion
• Commit to the principles of Person-Centred Care and to embedding these principles in all elements of service provision.
• Exhibit customer service beha...