1. Paul Gruen, Implementation Consultant
Bree Collaborative Implementation Survey Results for Medical Groups & Hospitals
Paul Gruen, Implementation Consultant

2. 13 Bree Collaborative Topics, 1 to 115 recommendations per topic
Obstetrics Care
Oncology Care
Cardiology: Appropriate PCI
Addiction & Dependence Treatment
CABG Surgical Bundle
Opioid Prescriptions
Spine/Low Back Pain
End Of Life Care Planning
Spine SCOAP
Avoidable Hospital Readmissions
Lumbar Fusion Surgical Bundle
Knee/Hip Replacement
Prostate Cancer Screening

3. Implementation Survey
Separate hospital and medical group surveys
Surveys are voluntary, self-reported (inter-rater reliability)
Bias towards larger urban & suburban systems
Implementation possibly independent of Bree Recommendation
Low implementation could mean “unknown”
Extensive length of survey reduced response rate

4. Participating Hospitals &Medical Groups
CHI Franciscan Health
Swedish/Providence
5 hospitals
5 hospitals, 3 medical groups
Confluence Health UW
Hospital & medical group
4 hospitals
The Everett Clinic
Vancouver Clinic
Evergreen Health Partners
Virginia Mason
Group Health
Northwest Physicians Network
Polyclinic

5. Implementation Scoring Scale
0 -No action taken 1 -Actively considering adoption 2 -Some/similar adoption 3 -Full adoption

6. MG #1: Addiction & Dependence Treatment (Average Score: 1.46)

7. MG #1: Addiction & Dependence Treatment (lowest scoring recommendations)
Verbal communication takes place with the chemical dependency treatment facility to follow-up on any referrals and assess whether treatment was initiated and/or completed (0.75)
The patient’s perspective is included as work is done to increase the capability of the chemical dependency system (0.75)
Patients are contacted after they have been referred to chemical dependency treatment to address any barriers to accessing treatment (0.88)
Patient results from alcohol and other drug misuse screens are tracked over time (1.00)

8. MG #8: Obstetrics (Average Score: 2.74)

9. Knee and Hip Replacement Surgical Bundle 11 hospitals 87 recommendations 2.32 Average Score

10. Knee and Hip Replacement Surgical Bundle (5 lowest scoring recommendations)
Cycle 2: General health questionnaire completed: Patient Reported Outcomes Measurement Information System-10/PROMIS-10 (1.09)
Cycle 2: Patient participates in Shared Decision-making with WA State- approved Decision Aid (1.36)
Cycle 2: HOOS/KOOS survey completed (1.60)
Cycle 4: Patient-reported functional outcomes are measured with KOOS/HOOS instrument (1.55)
Cycle 4: If opioid use exceeds six weeks, a formal plan is developed for opioid management (1.55)

11. Hospitals: Appropriate PCI / COAP (Average Score: 3.00)

12. Top BARRIERS to Adoption
Lack of availability & credibility of data, and burden to collect it
Business case- no economic reward, and lack of contract partners interested in value-based purchasing
Lack of consensus on what constitutes quality of care

13. Top ENABLERS to Adoption
Existing organizational improvement program for minimizing errors & waste
Business case- evidence of economic reward
Consensus on what constitutes quality of care
Individual provider-level performance feedback

14. Implementation- Key Lessons: 1 - 4
Systematic collection of patient self-reported goals, function & outcomes tracking are a challenge (STarT Back tool, Functional Recovery Questionnaire, Oswestry, PROMIS-10, KOOS/HOOS, Opioid pain assessment, Cancer Care treatment goals)
Patient Decision Aids not yet available and shared decision making not systematic (Prostate/PSA testing, knee/hip replacement)
Some recommendations may not be adopted as broadly as Bree specifies (advance care plans >18 y.o., drug & alcohol screening in ED >13 y.o.)
Communication between entities not systematic (advanced directives/POLST, PMP for Opioids)

15. Key Lessons: 5-10
Long-term opioid use planning a challenge, also Prescription Monitoring Program (PMP)
Addiction/dependency referrals, follow-up and tracking not systematic
Alignment with “Choosing Wisely” an opportunity (Oncology care, Prostate/PSA screening)
Decisions by “Collaborative Team” not yet systematic (Lumbar Fusion)
Data issues, business case for implementation significant barriers
Organization improvement program, business case, provider level performance feedback significant enablers

16. Next Steps (work in process)
Closer examination of providers successful in implementation
Work with health plans, particularly on business case
WA state “Business Group on Health”?
Healthier Washington/Hub, also Patient Decision Aids
Choosing Wisely
Bundled Payment specifications- revise/update