Reports The coding conundrum: a workplace perspective

Barbara Postle, Nadia Koeldnik and Tanya Miocevich

Abstract Over the last few decades clinical coding has grown in complexity and importance in the eyes of bureaucrats, administrators and clinicians, as new uses for this valuable resource are constantly being identifi ed. Anecdotal evidence suggests that many Australian are currently experiencing diffi culty in both recruiting and retaining clinical coders. The current shortage of clinical coders is a national problem, rather than being peculiar to any one state, and has a multitude of causes. This paper discusses a wide range of issues that have been identifi ed as being relevant to this situation, and they are elaborated from a number of viewpoints, including that of health information management. In this article suggestions for changes that could help rectify this situation are made.

Keywords (MeSH): Personnel Administration; Personnel Management; Mentors; Clinical Coding; Systems, Computerised; Australia.

For many managers, attracting and retaining that reflects the significant advances in clinical clinical coders can be a real headache. We are care that has occurred in recent times. an ageing society, which means that healthcare The outcome of all this is that coding work is is now a growth industry with beds time consuming and requires the employment of providing an apparently never-ending ‘turnstile’ highly skilled professionals in most workplaces, service. Most hospital Health Information and, in common with many health professions, Managers (HIMs) immediately link the word there is a national worker shortage. This is both ‘inpatients’ with the clinical coding they indirectly a blessing and a curse, depending on where you generate, and groan at the thought of managing stand. It is in the interests of everyone concerned the associated increase in workloads, backlogs in this area to look at the issues which have and deadlines which result from burgeoning brought about this situation, and how it might inpatient turnover. be improved. In addition, many clinical coders The sources of some of the headaches are realise that there is a level of ignorance in the easily identified; shorter lengths of hospital stays workplace outside of the health information mean admission of growing numbers of inpa- environment concerning just what clinical coding tients, that is, greater patient throughput; while is about. Generally, there is little understanding increasing longevity means that the modern amongst medical, nursing and allied health staff western lifestyle many of us have enjoyed now of the level of clinical knowledge and specialist has the opportunity to come back and bite us in skills that are required for accurate coding. When the form of so-called lifestyle diseases. To those clinicians become involved in research and want involved in clinical coding, these factors, together to abstract information from medical records, with a greater incidence of comorbidities, means however, the ’s knowledge and an ever increasing workload. In addition, coders ability to assist sometimes comes as a shock and are confronted with coding books that resemble pleasant surprise to them. To the HIM respon- a maze, mountains of rules and standards to sible for avoiding coding backlogs and submitting remember and an increase in coding complexity casemix data on time, this is often where the headaches start.

HEALTH INFORMATION MANAGEMENT JOURNAL Vol 38 No 1 2009 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) 47 Reports

Clearly, it is time to think ‘outside the square’ timeframes? Is documentation within the medical in order to maintain and improve clinical coding record of sufficient depth to support clinical services. As a starting point, we need to ask the coding? Are investigations and results available? following questions: Are there enough new coders Much of what happens within health informa- entering the profession? Is the work environment tion environments involves teamwork, regardless supportive? What can be done to retain coders? of the size of the service. Teamwork thrives on Is the pay fair for the level of skill required? What well thought out staff structures, communication, staff development opportunities are available clear standards and guidelines, up-to-date job for clinical coders? Can we ‘value-add’ to clinical descriptions, staff training and development and coding positions? Some of these questions are systems that function well. We were all taught general and pertain to the ‘big picture’; others can this in our training years, but we need to check be addressed at a more parochial level. that the theory translates into practice in the We feel that all HIMs must engage in and workplace. We also know that health information contribute to this debate either from the perspec- systems are far from simple and that one change tive of clinical coders who can articulate what is can sometimes have unintended consequences. needed, or from the perspective of line managers Timely intervention before problems grow out who have the capacity to improve systems and of proportion, communication, input from all the work environment. Heads of departments staff, and feedback to staff can help avoid pitfalls have the responsibility to advocate outside of and limit disharmony, all of which contribute to health information services for change. Yes, many a work environment where staff are valued and workplaces have limited flexibility about what respected. the HIM can or cannot do with regard to pay and Training and mentor support for beginner physical working conditions, but this should not clinical coders can help the transition of new be used as an excuse for not attempting a great coders to the workplace and provide a solid deal of reform. basis for professional development. Different At the outset, the extent of change that may mentoring models exist, depending on, for be needed can seem daunting. The old adage, example, the background of the new coder and ‘one bite at a time’, holds firm here. If we look at the size and location of the hospital. In larger what can be changed fairly easily and what is a hospitals, support for the ‘new kid on the block’ more difficult or long-term project, we can priori- is often provided in-house, whilst in small urban tise and make an action list. By taking on the hospitals and those in rural, and particularly more easily achieved tasks first, we can build on remote areas, mentoring may be external to success and work through the total list over time. the hospital or even the region, supplied by a The importance of the physical work environment government health department. Regardless of the is commonly acknowledged, but in reality many model, the key to the successful attraction and departments do not even have access to windows retention of staff is an understanding of the needs and natural light. Perhaps something as simple as of clinical coders and being able to support them a well chosen improvement in the general appear- in the performance of their duties without undue ance and aesthetic appeal of the workplace is a stress or frustration. good start. It is obvious that workstations should Australia has in effect a national clinical be ergonomically designed and the work environ- coding workforce. This is due to the roles played ment should be one that supports workflow and by the National Centre for Classification in coding related activities. Health and the Health Information Management More questions can now be asked: Is there Association of Australia, which offer coder IT support and Internet access available? Is the education programs and accreditation of health clinical coder’s computer capable of running information management courses. Coding issues all the desired applications? Are updates and such as salary entitlements therefore should be releases installed as soon as possible? Is there viewed from a national as well as local perspec- clerical support available to clinical coders? Are tive. In the area of recruitment and retention, discharge summaries completed within their remuneration rates cannot be ignored, particu-

48 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 38 No 1 2009 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) Reports larly in the present employment market where ment. Inexpensive incentives can sometimes it seems we have more vacancies than people to contribute to job satisfaction. Such factors as the fill them. This means that across the country, we flexibility of working hours, the ability to job- are ‘robbing Peter to pay Paul’, with staff moving share or work part time, organization of the work between hospitals, public and private sectors environment to meet a person’s social needs, or and even different states to better their working strategies to structure work so that it provides conditions or salaries. It is not reasonable to mental challenge and variety can be crucial to expect people to remain in a position which offers work satisfaction. There is nothing like asking a low pay rate with no likelihood of an increase; staff for their opinions in order to get feedback nor is it reasonable for the skills of clinical coders and to help us in understanding the issues and who have added responsibilities such as coor- concerns of workers in this key area of health dinating roles and responsibilities for statistics, information management. edits, Performance Indicators for Coding Quality Some of these issues and concerns are within (PICQ), or for the development of reports, to be the HIM’s sphere of influence, others are not. The unrewarded. ideal work environment is one where positive This raises another question: What we can do energy flows, where staff enjoy what they do and as individuals? This question can be answered enjoy coming to work. How difficult can that be from a number of perspectives. Certainly with to achieve? the increase in complexity of clinical coding and the increase in the level of skills coders need, in Reference some states a case could be mounted for better Maslow, A. (1943). A theory of human motivation. and greater equity in pay between the different Psychological Review 50: 370-396. sectors and states. This may apply in particular to coders working in casemix environments Barbara Postle BAppSc, PGradDipPubHlth where accurate coding and the understanding Program Leader of casemix systems can contribute to significant School of increases in hospital revenue. Curtin University of Technology From a number of perspectives it is important GPO Box U1987 that organizations that employ coders appre- Perth WA 6845 ciate the tasks they perform and of course strive AUSTRALIA to retain them in their professional roles. The email: [email protected] loss of clinical coders has financial repercus- sions for a hospital (apart from their role in Nadia Koeldnik attracting optimum funding, mentioned above); Clinical Coder the departure of experienced staff will inevi- Armadale Health Service tably result in the loss of corporate knowledge, Albany Highway while recruitment of new staff can be difficult Armadale WA 6112 and stressful. In some workplaces, there can be AUSTRALIA a work overload, leaving no other option but the employment of contract coders at high contract Tanya Miocevich BAppSc prices. Surely it is better to look at the big picture, Manager, Patient Information and Clerical Services diagnose any problems and do your best to attract Armadale Health Service and retain staff before this situation can arise? Albany Highway A high salary is not necessarily an overriding Armadale WA 6112 incentive for a person to remain in a particular AUSTRALIA position of employment. As Abraham Maslow Tel: +61 8 9391-2112 (1943) theorised in his famous ‘hierarchy of Fax: +61 8 9391 2149 needs’, once the fundamental physiological email: [email protected] requirements for existence have been met, a person might seek social and psychological fulfil-

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