1. Dr. Robert Bree Collaborative: Improved Quality and Outcomes through Transparency and Collaboration Steve Hill, Bree Collaborative Chair Rachel Quinn, Bree Collaborative Project Manager Ellen Kauffman, MD, Member of Bree Collaborative OB subgroup & Medical Director of OB COAP Healthcare PlexusCall, February 20, 2013

2. Dr. Robert Bree Collaborative - Background Created by Washington State Legislature in 2011. A public/private consortium of health care stakeholders - public and private health care purchasers, health carriers, and providers - working collaboratively to: ▫Identify topics/services where there’s “waste” or “overuse” ▫Recommend best practices based on data and evidence (if available) to Washington State to improve the quality, outcomes, transparency, and cost- effectiveness of health care 2

3. Dr. Robert Bree Collaborative - Mandate Annually, must select three health care services/topics with: Unwarranted variation High utilization and/or cost growth trends A source of waste and inefficiency in care delivery Patient safety issues Inappropriate care Proven means/strategies to address this topic (leverage other opportunities) 3

4. Dr. Robert Bree Collaborative - Mandate For each selected health care topic, the Bree Collaborative must: Identify evidence-based best practice approaches using data Recommend quality improvement strategies ▫Examples: Data collection, Patient Decision Aids, Centers of Excellence, Provider feedback reports 4

5. “Hook” of Bree Recommendations Washington State HCA administrator must review Collaborative recommendations and decide to adopt and apply them to state purchased health care programs, e.g., Medicaid, WA State Employee Health Care Plan, Labor & Industries, Corrections Intent is other public and private stakeholders will follow 5

6. Bree Year 1 Topics Obstetrics Cardiology Avoidable Readmissions ▫Total Knee Replacement and Total Hip Replacement Bundle Payments Acute and Chronic Spine Care/Low Back Pain 6

7. Obstetrics Care (OB) 1 st topic selected High unwarranted variation High volume and cost, and patient safety issue High priority for employers, especially Medicaid Approximately 85,000 births in WA State - Medicaid pays for half An opportunity to “scale up” great work done to date but with employers and health plans at the table 7

8. OB Report OB subgroup created in December 2011 ▫4 clinical experts plus employer, health plan, quality, and hospital representatives ▫Studied best practices, and existing local and national efforts to scale up strategies statewide 3 Focus Areas & Goals ▫Eliminate elective deliveries before the 39 th week, without a medical indication ▫Decrease elective inductions of labor between 39 and up to 41 weeks ▫Decrease unsupported variation among WA hospitals in the primary (first time) C-section rate 8

9. OB Report Findings & Recommendations Many reasons for variation: ▫Maternal requests and provider behavior ▫No universally accepted clinical guidelines or community standards exist for elective deliveries or elective inductions, or whether or when to perform a C-section once labor has started 5 Areas of Quality Improvement – “everyone has a role to play” ▫Commitment to Quality Improvement ▫Evidence-based or tested clinical guidelines and protocols ▫Transparency of data on selected OB procedures, by facility ▫Patient education ▫Realignment of financial and non-financial incentives Final OB report adopted by the Bree Collaborative in August 2012 and adopted by WA State in October 2012 9

10. Case Study – Franciscan Health System Management of Early Elective Deliveries Problem: National Leapfrog data showed high elective induction rate Ingredients for Quality Improvement Data (chart abstracted) Leadership: Physician champion & OB leaders Engagement of staff at all levels Provider and patient education System redesign – Feedback and Reporting, “Hard Stop” 10

11. Plexus Institute February 20, 2013 11

12. Bree Recommendations: 3 Goals Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012 12

13. Bree Recommendations: 3 Goals Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012 13

14. Bree Recommendations: Labor & Delivery ARMUS Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012 14

15. Bree Recommendations: Labor & Delivery ARMUS Bree Collaborative – Obstetrics Care Topic Report & Recommendations August 2, 2012 15

16. OB COAP Aggregate Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with Cervix on Admission >=4 Q1 - Q2 2012 Spontaneously Laboring Term Patients Admitted at >=4 cm): n= 1723 N = (cervix on admission) D = (labor type=sponteanous) + (woa >=37) + (parity CS=0) 16

17. OB COAP Aggregate Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with Cervix on Admission >=4 Q1 - Q2 2012 Spontaneously Laboring Term Patients Admitted at >=4 cm): n=1681 N = (CS=yes) or (oxytocin=yes) or (reg anesth=yes) or (LOTAD) D = (labor type=sponteanous) + (woa >=37) + (parity CS=0) + (cx on adm) 17

18. Questions? Comments? Robert Bree Collaborative ▫http://www.hta.hca.wa.gov/bree.htmlhttp://www.hta.hca.wa.gov/bree.html OB COAP ▫www.qualityhealth.orgwww.qualityhealth.org Steve Hill ▫Steven.r.hill@comcast.net Rachel Quinn ▫rquinn@qualityhealth.org Ellen Kauffman, M.D. ▫ekauffman@qualityhealth.org 18