POSITION:Team Leader,Clinical Coding
SERVICE:Directorate Information Management and Planning
LOCATION:Wellington Hospital
CONTRACT:Individual Employment Contract
HOURS OF WORK:Standard (full-time)
RESPONSIBLE TO:Manager Health Information Policy and Procedures
POSITIONS RESPONSIBLE FOR:7.7 FTE
( 7coders + .7 file assist)
FUNCTIONAL RELATIONSHIPS:Manager Health Information Policy and Procedures
Other staff in Health Information
eg :data quality facilitator
Other Capital Coast Health staff
E.g.: service leaders, team leader PIS, ward clerks, clinicians
External agencies – NZHIS (MOH)
BUDGET:
OPERATING ENVIRONMENT
Capital and Coast Health District Health Board is the principal provider of core health services to the people of Wellington, the Porirua Basin and Kapiti Coast.
The Information Management and Planning Directorate (DIMP) has overarching responsibility for Capital and Coast DHB’s (C&CDHB) information management and systems, organisational planning, reporting and projects.
Within that the Health Information Policy and Procedure team is responsible for the quality of health provision data collected throughout the organisation
JOB PURPOSE:
To be accountable for the efficient operation of the clinical coding service on a daily basis in order to achieve quality outcomes and meet contractual targets
The coding department’s primary objective is to:
Accurately translate clinical data from patient records into a coded format in a complete and timely manner whilst adhering to national coding standards
RESPONSIBILITIES:
- Manage the daily inflows and outflows processes of the patient medical record files within the coding dept
- Ensure that coding team meet organisational and contractual targets in relation to productivity ,timeliness and quality standards
- Liase with and provide updates to team leaders, clinicians, ward staff and others as appropriate at ward level about coding standards and other coding related issues
- Liase effectively with agencies such as the National Health Information Service of the Ministry of Health (NZHIS), National Centre for Classification in Health(NCCH), New Zealand Coding Authority (NZCA), on clinical coding issues and matters
- Provide regular reports to the Health Information manager and service leaders on number of uncoded events per service and documentation issues
- Provide other monitoring reports as requested to the Health Information manager e.g. :productivity and accuracy reports
- Maintain clinician education programme and ensure ongoing review of relevant clinical documentation
- Design and implement a plan for regular audit of discharge coding across the specialities
- Work co-operatively with management to support and develop a motivated and appropriately skilled team of staff
- Model good staff and client relations based on values of team work, innovation, creativity, respect, cultural sensitivity and conservation of resources
- Assist manager to monitor HR processes within coding department
- Assist and advice management on coders participation in training courses and ongoing education
- Maintain effective communication and functional relationships with staff and wider networks
- Contribute fully and effectively as a member of the Health Information team
The Health Information Manager may need to add to or amend these duties after consultation with the Team Leader
Individual performance objectives and criteria will be based on this position description and appropriate operational plans
Revised
28th September 2001
COMPETENCIES
Team leader - Clinical coding
The person in this position will exhibit the following behaviours and qualities, which have been defined as contributing to effective performance.
- Clinical coding information
Follows processes to ensure accurate, complete and timely clinical coding data. Adds value to this by keeping up to date with clinical coding requirements and ensures all coders are aware of the requirements and changes. Goes out to personally investigate the problem or situation in the services relating to clinical coding issues coding. Questions and consults those closest to the problem. Consults available documents. Knows where to look if the answer is not readily available.
2. Understanding Context
Understands and uses the formal structure of Capital and Coast District Health board.
Understands where Capital and Coast hospitals fit into the structure of the health and public sector. Knows the parameters of their responsibilities and seeks approval as necessary.
3.Planning and organising
Thinks ahead several moves and takes action to prepare for foreseeable problems. Develops work plan to ensure work stays on track but able to replan and to deal with changed priorities.
4.Analysis
Makes appropriate links. Makes decisions by basic analysis and comparison (e.g., develops a pro/con list, and establishes priorities).
5.Judgement
Makes sound decisions in new but unambiguous situations, e.g., establishes priorities in accordance with the section's priorities. Must have ability to make own decisions.
6.Written Communication
Communicates ideas so that they are easily understood. This includes writing that is grammatically correct, following plain language and Capital and Coast principles.
7.Spoken Communication
Approaches people with a non-judgmental attitude. Is accessible and open to others' views. Uses simple examples and describes problems in terms of cause and effect. Persuades by pointing out the benefits and appealing to logic.
8.Networking
Shares appropriate information with others, e.g., maintains mailing lists, databases of contacts.
9.Teamwork
Gets involved in team activities. Contributes to discussions but not at expense of work deadlines. Is prepared to undertake a variety of duties to achieve team goals. Pitches in to help when necessary. Maintains discretion. Respects the views of others and does not override the contribution of others.
10.Client Service and Advice
Works to understand the client's environment. Keeps up to date on changes. Asks questions to determine what the client really wants. If can't respond may just take detail but will strive to get back to them. Follows up on own client to ensure the service was appropriate.
11.Adaptability
Maintains performance across a wide range of tasks and roles.
12.Organisation Commitment
Demonstrates a positive approach and commitment to work. Demonstrates a motivation to improve Capital and Coast work, relevant to own area of input/specialisation. Actively supports and promotes Capital and Coast mission statement and goals, philosophy and values.
13.Initiative
Ability to make decisions and respond to requests without guidance. Notices that something needs to be corrected and takes action. Takes responsibility and accepts accountability for all personal transactions. Recognises how useful ideas generated by other work units can be applied to own work/area.
14.Maintaining and Sharing Expertise
Keeps up-to-date on skills. Regarded as credible by others in technical/professional field. Applies their knowledge appropriately to the job. Forms opinions and solutions, which are technically, sound. Seeks and accepts feedback. Approaches new problems eagerly.
15.Achieving High Quality Results
Manages own workload effectively to meet deadlines, milestones and quality standards. Distinguishes important deadlines from others and may renegotiate the deadlines as required. Uses peer review where appropriate.
16.Demonstrated ability to incorporate Treaty of Waitangi principles and bicultural partnership into personal practice.
PERSON SPECIFICATION
KNOWLEDGE, EXPERIENCE, SKILLS AND ATTRIBUTES
REQUIRED FOR THIS POSITION
- Completed a recognised certificate in Clinical Classification
- Minimum two years coding experience at a tertiary hospital
- Have proven leadership and change management skills
- A commitment to coding quality and ongoing coder education
- Experience or knowledge of coding audit activities in a hospital setting
- Demonstrated communication and interpersonal skills
- Proven organisation skills with the ability to work under pressure and prioritise work tasks
- Ability to proactively problem solve
- Experience with computer applications including hospital and PC based applications and 3m Codefinder
- A commitment to working as part of a team
- An interest and commitment to the Health sector , the goals of the unit and the company
- An understanding of the Privacy Act pertaining to confidentiality of Health Information
- Knowledge of Ministry of Health reporting requirements an advantage
28th September 2001
Prepared by
Glenys Checchi
Health Information Manager
D.I.M.P