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November 28, 2016

Lean, CERT, and Chiropractic Services

CGS partnered with Lean Enterprise Institute (LEI) to conduct a Lean event that focused on reducing the Comprehensive Error Rate Testing (CERT) errors for Chiropractic services.  The 2015 National CERT report  revealed that Chiropractic services had a 51.75% error rate with 95.8% in error due to insufficient documentation. 

As a result of this project, CGS wanted to focus on the following:

  • Identify driver of the error rate
  • Collaborate with Chiropractic State Associations
  • Conduct written and teleconference education for the pilot providers
  • Conduct a 2-3 day onsite with the provider
  • Conduct 3-4 follow-up teleconferences to refine the process.

Two Part B Chiropractic providers were selected to participate in the Lean event.  A probe had been conducted on these providers, each having a 100% error rate.  The two providers were transitioned to prepay targeted review.  Prior to the initiation of the Lean event, the error rates were 70.8% and 78.7% after traditional education techniques were provided. 

Some of the findings identified during the reviews of the two selected providers were:

  • Vague or no measureable goals documented
  • Possible cloning (with the use of Electronic Health Record (EHR) software (this is common))
  • The chief complaint was not clearly stated (for example, was this an exacerbation or new injury)
  • No specific and measurable long term goals listed
  • The technique or type of manual treatment executed such as manual, drop table was not documented; only chiropractic manipulative therapy was listed.

The objectives of the chiropractic Lean project was to:

  • Identify and agree on a problem
  • Collaborate on a set of potential solutions
  • Experiment in order to identify the best solution
  • Communicate, share and learn from the results.

CGS, in addition to LEI, conducted a two-day onsite visit with the two selected providers.  During these visits to each provider’s office, Value Stream Improvement (VSI) process was used.  The definition of this process is to look at the delivery of services as a stream of activites that all participants along the way can create value that meets the needs of the consumer and eliminates those activities that do not add value.

During the visit members of CGS and the LEI staff:

  • Observed patient flow
  • Observed documentation process
  • Evaluated EHR
  • Mapped errors  to CGS’ LCD (L33882 – Chiropractic Services)
  • Compiled experiments/counter-measures
  • Through trials/refinement/visual management we were able to change some documentation processes
  • Implemented revised process. 

Upon leaving both sites, the providers sent samples of documentation for review and additional education was provided as needed.  Upon implementation of the improved process in documenting clinical notes and each provider making tweaks to their individual EHR systems,  individual error rates decreased to 26.2% and 9.3%.  Both providers were removed from targeted review as a result of the improved error rates.  Further review, after removal from targeted review, showed an improvement to  0% error rates. 

With the success among the two selected providers, CGS’ goal is to work with additional providers and other specialties in effort to reduce the CERT error rate.  Continue to watch CGS’ website for other initiatives to reduce the error rate.  Also, stay  tuned for a chiropractic webinar targeted for early 2017.

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