Steve Hill, Bree Collaborative Chair Rachel Quinn, Bree Collaborative Project Manager

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

3. Dr. Robert Bree Collaborative - Mandate Annually, must select threehealth 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)

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

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

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

7. Obstetrics Care (OB) • 1st 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

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 39th 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

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

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”

11. Plexus Institute February 20, 2013

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

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

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

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

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)

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 (reganesth=yes) or (LOTAD) D = (labor type=sponteanous) + (woa >=37) + (parity CS=0) + (cx on adm)

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