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!
For our first CDS Snapshot of 2023, we’re talking to Stephen Kennett from Mulgrave Private Hospital in Victoria. Stephen’s diverse experience prior to working in healthcare has enabled him to be a strong communicator and excellent problem solver.
Tell us about your current role
I am now a CDS at Mulgrave Private.
What is your career background, and how has that contributed to your ability to work as a CDS?
I have worked in the food industry as a manager, in hotels and the fast-food industry, then began nursing in 1996. I have completed my Bachelor of Nursing, then Graduate Diploma in Critical Care and also a Graduate Diploma of Health Industry Management. I feel this has enabled me to be a good communicator with great interpersonal skills, have a good clinical knowledge, and build a good rapport with most of the medical staff and staff in general within the hospital in my previous role as NUM. I have worked in the public system and now been in the private sector for around 15 years.
What made you apply for a CDS role?
This is a new area for me, and I love learning about how the diagnosis is coded for payment. Along with this is a passion for the notes to reflect the actual clinical truth, to ensure everyone involved in the patient care can clearly see what is happening and what the plan is for treatment. I also saw the need for someone with clinical expertise and good relationship skill to be involved in this role, and I felt could make a great contribution. This is something I felt I would enjoy and would be able to help improve patient safety.
What does your typical day look like?
Normally I will come in and will print out the hospital patient list and highlight any patient I need to review (from the previous day). I will go to each ward I am reviewing the patients on and chat with the staff. I’ll review the patient files and flag any patient inquiries I need to complete. Then I will go back to the office and enter the patients into code finder and then code focus. I will talk to any doctors I can and sometimes they will update their notes. Then I like to talk to the ward staff about the importance of documentation and the role they can play, as part of the diagnosis team. Case mix is very helpful, which is on Tuesdays and Fridays, a chance to clarify many things.
What was the moment CDI really “clicked” for you?
I suppose it came early on, when I saw how we can make a difference, not only to the profitability, but to patient safety and documentation. Also, when I increased my knowledge around coding and the role it plays in deciphering the extensive patient notes.
How would you describe your personal CDI philosophy?
I think it’s about ensuring the documentation is accurate. It seems like a simple thing to do, but it takes constant reinforcement to achieve consistency. I love to be a part of this process and the knowledge I have gained is exciting for me. I love this role!
What is the biggest challenge you have faced as a CDS?
I think it’s been the medical staff: some of them still think any shorthand they use should be interpreted into a diagnosis. Some say they don’t have time and others see it as not their problem. On the other hand, most are very good when I talk to them, and listen.
What is the most memorable “win” you’ve had?
I think moving an F04B to an A by engaging with the doctor and putting in an enquiry, following it up and getting them to sign it after a number of discussions.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
Why are you doing that, it’s not that important and being at the coalface is much more interesting, with patients!
Favourite DRG?
I don’t really have one.
Favourite additional diagnosis?
Anaemia, because it’s the one that is least documented accurately!
What are excited about in the future of your role?
The more I learn the more I want to know and I can see I will make a big different, ultimately to patient care, which will be great. It’s a role I can grow and expand, it is never dull or boring to me.
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.