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 Stefan Blazy, CDS at Ramsay Health Care's St George Private Hospital. Hear about Stefan's incredible story moving from Germany, having to qualify and retrain to become a nurse, and his foray into CDI. Stefan's 3-point personal CDI philosophy has seen him successfully lead change in documentation quality across his organisation.
Tell us about your current role
I am currently working 1 day per week as a Staff Health CNS, managing the Vaccination Program for 1,000+ Staff as well as the Pre-Employment screening for all new recruits. The other 4 days of the week I work as the CDS and site administrator for our Electronic Discharge Summary system.
What is your career background, and how has that contributed to your ability to work as a CDS?
I started Nursing in Germany back in 1998. After completing my apprenticeship, I worked briefly as a triage nurse in an Emergency Department. However, the transition from Nursing student one day to E&D triage nurse the next day was too much for me….I lasted 1 month before moving to a Urology Ward for the next year. Since I always had interest in mental health, I asked to be moved to a Psychiatric Ward (at the same Hospital) after 1 year. I stayed on this ward (mainly for Patients with Alcohol and Drug Addiction) for the next 6 years before moving to Australia.
In Australia I worked for about 1.5 years as a Disability Support Worker before starting at SGP as a Wardsman. Coming from Germany, where the education system for nurses is a bit different I had to go through a long skills assessment process (took 2.5 years) until the Nursing and Midwifery Board in Australia decided that my training was equal to Australian standards. After about 1 year as a porter/driver/car park attendant I started working in our Stores Department for a short period of time. Then, when finally my Nursing Registration came through I was put into a new Grad program that was just about to start (I had a lot of luck with the timing). My first rotation as a new grad was on the Orthopaedic Ward (for 6 month) and then Endoscopy Department as 2nd rotation. I loved working as an anaesthetic nurse in endoscopy and gained a lot of knowledge which helped me later on in my career. After completing the new grad program I was offered a full-time position as RN on our Orthopaedic ward where I stayed for about 10 years. In this time I started to take on clinical facilitating of students, being in-charge of the ward afterhours and being an associate for Infection Prevention & Control and WHS. In September 2019 I applied for my current position as Clinical Documentation Specialist and was also given the opportunity to take over the Staff Health Portfolio at SGP.
What made you apply for a CDS role?
Apart from being an interesting, challenging and rewarding role (all at the same time)….after more than 20 years of shift work, I really enjoy working normal hours (especially with a small child at home).
What does your typical day look like?
There is no “typical day”. Every day throws new, often random challenges at me. I try to establish a routine of checking/auditing an x-amount of records but since the main aspect of this job is to liaise with clinicians from different backgrounds, sometimes you come across people that you just have to spend a little bit more time with to get the message across.
What was the moment CDI really “clicked” for you?
When I first stepped foot into the medical records department and learned about the job our clinical coders are doing, that was a bit of an eye-opener. I never knew to what detail they need the information documented to assign the correct codes.
How would you describe your personal CDI philosophy?
There are 3 key points that I always valued.
What is the biggest challenge you have faced as a CDS?
When I was new to the role I found it challenging to speak to Groups of Doctors (and tell them what they are doing wrong) and hospital executives.
What is the most memorable “win” you’ve had?
Raising our overall Hospital compliance with Clinical Documentation from 43% to 72% in just 6 months through Staff training, amendment of forms and repeating myself over and over again 😊.
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-year younger me would probably crack up laughing (because back then I had no idea about how important quality documentation is).
Favourite DRG?
The one that I moved to an A.
Favourite additional diagnosis?
Constipation – The look on the clinician’s face when I tell them that “BNO 4 days” is not good enough can be very entertaining.
What are you excited about in the future of your role?
EMR – I have not worked at a hospital that uses an electronic medical record and am looking forward to the transition (whenever that’ll be). Even though it is not going to negate all documentation issues, the fact that we don’t have to decipher handwriting anymore, would make the job 100 times easier.
Want to be the next CDS profiled on CDS Snapshot? Contact us at community@cdia.com.au.
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