OB Report & Implementation Plan

1. OB Report & Implementation Plan Bree Collaborative Meeting August 2, 2012

2. Outline of Presentation & Actions Needed from the Bree Collaborative • To present and discuss new edits in OB report • To discuss Patient Decisions Aids – a new proposed addition (not yet incorporated in report) • To discuss and get Bree Collaborative members’ feedback on OB implementation plan • 2 Proposed Action Items: • Adopt OB report (with or without changes) • Adopt implementation plan

3. Finalizing OB Report - RECAP • The Bree Collaborative at its May 31st meeting approved OB report with small changes to employer/payer recommendations; gave authority to steering committee to finalize the report • OB subgroup on June 19thwere asked to endorse final report (because some subgroup members could not join the May 31st meeting due to phone issues) • Subgroup members’ small editorial edits incorporated into report • Steering Committee approved final report on July 3rd • Additional edits were proposed and asked to be considered on July 6th

4. New Edits • Remove words “Hard Stop” in hospital and employer/purchaser recommendations • Nomenclature change; content/intent did not change • Words “hard stop” still used in OB Effective Programs section (pg 6) & Franciscan Case Study • Elevate “consultation” requirement from footnote to body prose • Revise Labor and Delivery Guidelines for C-Sections • Precision added • Verbs more affirmative in tone

5. Edit #1: Hospital Recommendation (pgs 10 & 11) • Old: A type of Hard Stop Policy for Scheduling Elective Inductions/Deliveries/C-sections (using The Joint Commission and State of WA lists) • New: “Guidelines for Scheduling Deliveries before the 39th week: Hospitals should implement a policy for scheduling deliveries before the 39th week that includes the following two components: • The indication must be on The Joint Commission or the Washington State list used in the current elective delivery between 37 the 39 weeks Washington State Perinatal Collaborative/WSHA project; and • For clinical situations not on the two lists listed in number one above, consultation must occur and agreement must be obtained that the clinical situation requires delivery.

6. Edit #1 con’t: Employer/Purchaser Recommendation Edit (pg 13) • Old: Require hospitals and physicians to implement a “hard stop” scheduling policy on elective deliveries or C-sections prior to 39 weeks or require pre-authorization; (pre authorization process should reduce burden on practice when performance is demonstrated) • New: Require hospitals and physicians to collaboratively implement scheduling policies on elective deliveries before 39 weeks and elective inductions of labor between 39 and up to 41 weeks in accordance with guidelines proposed for each procedure at the bottom of page 11/ top of page 12, or require consultation for acceptance of exceptions

7. Edit #3: First two bullets of Labor and Delivery Guidelines for C-Sections (pg 11) Old • Restrict admission for spontaneously laboring patients to those whose cervix is dilated to 4 centimeters or more; • Avoid C-section for first stage arrest in the latent phase; New • Admit only those spontaneously laboring women at term who present with no fetal or maternal compromise when the cervix is 4 centimeters or more dilated. • Allow first stage labor arrest cesarean (reassuring fetal and maternal status but lack of progress of labor) to be performed only in the active phase (equal to or more than 6 centimeters dilation).

8. Patient Decision Aids • Proposed strategy to be added to “WA HCA and WA DOH Recommendations” (pg 12) Assist practitioners and facilities with the provision of easily accessible, state-certified Patient Decision Aids (PDA’s) which will provide unbiased balanced information and a consent format for patients regarding risks and benefits of procedures or treatments, such as elective induction less than 39 wks, primary C/section by maternal choice, etc.  PDA's protect both the patient and the practitioner/facility by the clarity of the information provided.  If there is a legal action based on lack of informed consent, a PDA provides "prima facie evidence (evidence that will prevail unless rebutted by clear and convincing evidence) of informed consent that the patient or his or her representative signed an acknowledgement of shared decision making.“ • [Existing RCW 7.70.060  now specifies that certification is the responsibility of the Medical Director of  WA State Medicaid if there are no national or international organizations which have certified PDA's].

9. Submission to HCA • Per Bree legislation Bree must send report with cover letter to HCA administrator with chosen topics & proposed strategies (not just OB) (Target date: August 6th) • HCA administrator must review the strategies and recommendations and make a decision whether to adopt and apply recommended strategies to state purchased health care programs. • Following the administrator’s review, the Bree Collaborative must report to the legislature and the governor regarding proposed strategies and the results of the administrator’s review (Proposed target date: August 30th)

10. OB Implementation Plan

11. OB Implementation Facts & Ideas • Nothing in Bree legislation about Bree’s role in implementation of recommendations • Little funding for implementation activities Given the facts… • Bree Collaborative Steering Committee gave feedback on earlier draft plan during July 3rd conference call • Leverage existing efforts and networks & work with partners to maximize reach • Everyone has a role to play to promote report and its recommendations • Governor Gregoire • State agencies – Dept of Health; WA Medicaid; Health Care Authority; PEBB; and Dept of Social and Health Services • Partners – March of Dimes, WSHA, WSMA, WA Obstetrical Association, and PS Health Alliance • Bree Collaborative Members

12. Proposed State Agencies’ Roles (vs. Bree)

13. Main Implementation Activities conducted by Bree Staff, by Stakeholder • All Stakeholders & Partners, local and national • Send copy of the report • Employers and Purchasers • Present to employers and employer groups • Provide announcement in in-house newsletters • Hospitals • Send letter and report to all WA hospitals with obstetric departments (letter addressed to CEO, OB Chief, & medical staff president) • Present to hospital boards

14. Main Implementation Activities conducted by Bree Staff, by Stakeholder, Con’t • Health Plans • Convene meeting with all WA health plans to discuss quality initiative & bundled payment reform ideas • Individual Providers • Collaborate with key obstetric partners (WA Perinatal Collaborative, ACOG-WA, WA State Obstetrical Association, WSMA) • Media • Pitch report to health reporters throughout WA

15. Timeline at a Glance

16. Proposed Partners • Bree members • All WA health plans • WA Hospitals • WSHA & WSMA • March of Dimes • WA State Perinatal Collaborative • ACOG-WA, WA State Obstetrical Association • Legislators • Employer groups (through the Puget Sound Health Alliance, WA Roundtable, WAB, Seattle Chamber) • Employers (King County, REI, Boeing, etc) • National groups: Leapfrog, Consumers Union, Childbirth Connection, Catalyst for Payment Reform, OB experts • Insurance Commissioner

17. Next Steps • Create an OB Implementation Plan Advisory Group (to help guide implementation efforts) • Report to the Bree Collaborative (updates at Bree meetings) • Members of the OB Subgroup/representatives from different stakeholder groups • Proposed: Theresa Helle, Ellen Kauffman, MD, and Mary Kay O’Neill, MD • Collaborate with State Agencies on implementation