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 this instalment, we're back in the capital, talking to Jocelyn Cox from The Sydney Adventist Hospital. Hear how Jocelyn has improved documentation of the cause of abdominal adhesions by 85%!
Tell us about your current role.
I am the first Clinical Documentation Specialist at The Sydney Adventist Hospital, appointed July 2020. As Coordinator of the Clinical Documentation Improvement initiative, I am responsible for implementing the program. This involves clinical – based concurrent patient reviews of inpatient episodes; hospital wide education of Doctors, Nurses and Allied Health; and the development of documentation policies, procedures and processes. To encourage improving clinical documentation as a team within the organisation I am always working on building relationships with Health Information Managers/Clinical Coders. I also seek training and support from Clinical Coders to develop my skills as a CDS so I can resolve issues with clinical documentation that impact the clinical coding and billing/revenue functions.
I am a member of the Forms Committee and National Standards 6 Communicating for Safety Committee. I am also involved in trying to improve AMO compliance with Electronic Discharge Summaries and also have been instrumental in setting up a new process for the timely completion of 3B certificates with key stake holders.
What is your career background, and how has that contributed to your ability to work as a CDS?
I trained as an RN in the UK and worked and travelled in the UK and South Africa in many specialties. I have worked at the Sydney Adventist Hospital for 20 years. I was the Acting NUM of the Neurosciences Ward and then I was then the Case Manager for 10 years. Case Managers monitor length of stay and have some knowledge of health fund contracts. I was seconded to a Health Fund Audit Review position for 2 years and that role prepared me for the CDS role.
What made you apply for a CDS role?
I was encouraged to apply for the role by my Director who was involved in the negotiations with CDIA. As I have worked at the hospital for 20 years in senior positions, I have developed effective communications skills and a good rapport with AMOs/VMOs. Implementing CDI into the organisation requires a ‘culture change’, so even though an external CDS applied for the role, I was chosen as I better understand and support the mission of Adventist HealthCare and associated challenges. I thought I had done my homework about what the CDS role entailed – but it was a far higher learning curve than I anticipated and, as I do not have project management skills, I struggled in the beginning.
What does your typical day look like?
I review and respond to e mails. I follow up on any queries I have generated the day before. I print off the ‘Coding for Complexity Report’ for the wards, ICU/CCU that we have designed along with our IS Department. Sam from CDIA calls this form “Gold”!! It selects MB, BUPA, Alliance patients and captures specific diagnoses, eg: Division of Adhesions, Abnormal HB or electrolytes, Delirium, raised CRP, Diabetes, ICU >3 days to name a few. I will then decide which patients to review that day. I may present a CDI Presentation to new Registrars/Interns or New Grad RNs on their Orientation day. I meet with Case Managers who also review 2 – 4 patients a day for CDI and provide some education based on the feedback from the CDI Communication Tools we have received back from Clinical Coders. I meet and liaise with Medical Records and The Health Fund Relationship Director regarding education, issues and processes. I also liaise with Heads of Medical and Surgical Services to discuss any non-compliant AMOs who are resistant to update their Procedure Reports or clinical notes. As the hospital has been Code Red due to Covid-19 restrictions, we have to remain within our ‘bubbles’ in the hospital, so I have been unable to provide face to face CDI Presentations on the wards. I am hoping this will be lifted soon, as I do not want the CDI Initiative to lose momentum.
What was the moment when CDI really “clicked” for you?
I’m not sure if there was one moment, but certainly when revenue reimbursement increased as a result of my impact, I felt some success had been achieved and was motivated to continue to spread the CDI message!
How would you describe your personal CDI philosophy?
My role as a CDS is to improve clinical documentation throughout the organisation, through concurrent reviews for completion and accuracy of information in the record, where the aim is to capture the clinical truth, and engagement of staff through education. The main focus is on documentation for quality, patient safety, education and appropriate reimbursement. So my personal philosophy is to utilise all my years of nursing experience to help me practice my CDS role effectively.
What is the biggest challenge you have faced as a CDS?
Probably the doctors who have some knowledge of CDI, but not all of it is correct! Resistant AMOs, who will not take the time to learn about my CDS role when I am requesting updates, so they do not understand the rationale behind CDI. I have also avoided presenting during my 45 years of nursing; it is not something I am comfortable doing, even harder while still learning my CDS role, but I am improving and receive positive feedback.
What is the most memorable “win” you’ve had?
Improving the documentation by at least 85% on the Procedure Reports of the ‘underlying cause of adhesions’ when AMOs document Division of Adhesions. There has been a lot of education with the surgical AMO’s about why it is important to always document the cause of the adhesions, this specificity can impact the DRG in some cases and since March 2021 has generated over $70,000. I rarely have to contact Surgical AMOs now, as their documentation has improved dramatically.
If you could talk to yourself 10 years ago and tell them you’re now a CDS, what do you think they would say?
I think I would be extremely surprised, I did not know this role even existed or how important it is to every organisation 10 years ago. I would probably think I could never accumulate the knowledge required to be a CDS or that it would be something as an RN that I would enjoy, as there is no patient contact or that I would have financial KPIs!
Favourite DRG?
G02B - Major small and large bowel procedures, as there is often an opportunity to increase specificity and associated diagnosis
Favourite additional diagnosis?
K9189 - other intraop and postprocedural disorders (division of adhesions due to previous surgery), it is rewarding to see this coded on a regular basis now, due to AMOs improved documentation.
What are you excited about in the future of your role?
I am excited to see how my CDS role evolves within the organisation and if the CDS team will increase, as I strive to demonstrate the positive impact and benefits of the CDI initiative at The San.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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