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 Clare Tosoni, CDS for UnitingCare at The Wesley Hospital in Queensland. Here how Clare's knowledge in healthcare quality and coding has empowered her to build an effective CDI program, where even the most challenging of specialists have become engaged with CDI! Here is Clare's story.....
Tell us about your current role
I am one of two CDSs currently working across the UnitingCare group of hospitals, based at the Wesley Hospital. I have been in the position since the Introduction of a CDS program at the hospital and have over time been able to develop the program to what it is today. My responsibilities include concurrent chart review, coder support and education, training new team members, education to coders, students, graduate groups and hospital staff. I also present data to doctor specialist groups and work with them to understand coding and data and its impact on and the patient groups they care for.
What is your career background, and how has that contributed to your ability to work as a CDS?
I have a background in general medical and surgical nursing, many years spent in management of acute wards and services including hospital flow, which gave me good insight and broad knowledge of a large tertiary hospital.
In the last decade, I have worked mainly in Quality and Safety roles, including Mortality and Morbidity portfolio, and documentation design and management. This is where the foundations of documentation and its impact on health outcomes became apparent to me. I also audited charts and focused on DRGs and LOS relationships, which gave me a taste of the clinical coding world! When I commenced as a CDS I decided I wanted to really get into understanding coding, so I completed a coding qualification which has been endlessly helpful.
What made you apply for a CDS role?
I was ready for a challenge and understood clinical coding and the data it provided was an area that interested me (self confessed data nerd!). I felt that coding and coded data was under-utilised and not understood well by clinicians generally, and was interested to explore the opportunity of learning more and influencing change with my new knowledge.
What does your typical day look like?
Most days I will share my time out on the wards with other clinicians, reviewing medical records and working with the clinical team to improve documentation. A good part of my job is relationship building which allows these conversations to be less direct. I also spend some of my day supporting coders with clinical input and chart reviews retrospectively, providing education on wards and tracking queries and data.
What was the moment CDI really “clicked” for you?
About 6 months into starting as a CDS I started really seeing good improvements in documentation in the areas I worked. I was deep into my coding course at the time and I think it all sort of fell into place quickly from that time on.
How would you describe your personal CDI philosophy?
I see myself as a part of the healthcare teams I support. I feel by helping the clinicians understand their ability to influence their financial environment with better documentation and equating it to patient outcomes, it really speaks to those teams. It is being able to articulate that both quality patient care and financial sustainability is everyone’s responsibility. My job is to empower them and work behind the scenes to protect the healthcare environment, staff and patients!
What is the biggest challenge you have faced as a CDS?
Maintaining momentum when the team is so small.
What is the most memorable “win” you’ve had?
Developing relationships and positive documentation change with specialist doctors renowned for being obstructive and difficult. Not only do we have better documentation, but we also have fabulous engagement from some of these staff members.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
Really? Well, didn’t the hard times and work pay off!!
Favourite DRG?
It is a tie: G02 and F04
Favourite additional diagnosis?
Delirium or antibiotic resistance
What are you excited about in the future of your role?
I see a bright future where we understand data better. The value of that clinical lens that a CDS offers is the missing link in the boardroom to the patient room. Being able to support teams, executive members and boards see the influence and manage care better with this insight is a very exciting journey to be a part of.
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.