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 Rincy Varghese, CDS for Counties Manukau at Te Whatu Ora - Health New Zealand. Hear about Rincy's journey and the progress she has made engaging with clinicians and changing behaviour in a large health service. Here is Rincy's story.....
Tell us about your current role
I am one of the two CDSs at Counties Manukau Health, New Zealand and have been in the role since the programme's introduction in 2021. My responsibilities include performing concurrent chart reviews, engaging with clinicians to provide real-time feedback on clinical documentation, and building relationships with the clinical coding team to improve clinical documentation and enhance inpatient health data.
What is your career background, and how has that contributed to your ability to work as a CDS?
I have over 10 years of medical, surgical, and trauma intensive care nursing experience, which has helped me gain extensive clinical knowledge and sparked my interest in quality improvement initiatives. I am also interested in the data and health informatics side, which has helped me in my CDS role.
What made you apply for a CDS role?
I was ready for a challenge and had been trying to move into the Health Informatics space. Then I heard about the CDS role at Counties and thought this was the job description I had been looking for.
What does your typical day look like?
My day typically includes identifying patients to review for the day. I start with the surgical acute list to look for cases with potential high-value DRGs and then continue reviewing patients on the ward. In saying that, no day/week looks the same; it could vary from record reviews to attending meetings and delivering education to clinicians. A crucial part of the role is relationship-building with the various stakeholders, from clinicians to the steering group and, at times, with the senior leadership teams. Some days are occupied with creating educational content for clinicians and analysing data for reporting.
What was the moment CDI really “clicked” for you?
There has been understandably exceptional resistance from various stakeholders at the infant phases of the programme. However, after showing them the impact of accurate documentation and its relationship with clinical complexity, I noticed a gradual culture change in the documentation amongst senior clinicians- that moment clicked for me.
How would you describe your personal CDI philosophy?
Engagement and empowering clinicians. I always tell them I am not here to make their lives difficult but to help “in the long run”. CDI is so much more than just getting the diagnosis documented.
What is the biggest challenge you have faced as a CDS?
Physician engagement and CDI recognition. Clinicians think I belong to the coding team and are more keen to learn about clinical coding rather than documentation. I have also been termed a “coding lady”😊 However, I have seen a gradual change in clinicians' perspectives over the years I have been in the role.
What is the most memorable “win” you’ve had?
Clinicians using “due to” has undoubtedly been a win for me. I have also noticed surgeons documenting “adhesions due to previous surgery” consistently, considering the lack of buy-in at the programme's start.
If you could talk to yourselves 10 years ago and tell them you’re now a CDS, what do you think they would say?
I’d be like, ‘What in the world is that’? The 10-year-younger me would be surprised to see such a career progression (using my clinical skills and passion for quality improvement).
Favourite DRG?
G02C - Bowel procedures.
Favourite additional diagnosis?
Delirium and UTI - are often poorly documented and a common cause of increased LOS in surgical patients. It is interesting how it hugely contributes to reflecting the clinical complexity.
What are you excited about in the future of your role?
CDI is an ever-evolving concept, especially in Aotearoa, and I am very hopeful and eagerly waiting to see how the current health reforms will shape the future of CDI.
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.