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
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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 costeffectiveness of health care
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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)
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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
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“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
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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
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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
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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
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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”
▫
▫
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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
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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”
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Plexus Institute
February 20, 2013
Bree Recommendations: 3 Goals
Bree Collaborative – Obstetrics Care Topic
Report & Recommendations
August 2, 2012
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Bree Recommendations: 3 Goals
Bree Collaborative – Obstetrics Care Topic
Report & Recommendations
August 2, 2012
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Bree Recommendations: Labor & Delivery
Bree Collaborative – Obstetrics Care Topic
Report & Recommendations
August 2, 2012
ARMUS
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Bree Recommendations: Labor & Delivery
Bree Collaborative – Obstetrics Care Topic
Report & Recommendations
August 2, 2012
ARMUS
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OB COAP Aggregate
Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with
Cervix on Admission >=4
Q1 - Q2 2012
47%
0%
10%
20%
53%
30%
40%
Patients Admitted w/Cervix on Adm <=3
50%
60%
70%
80%
90%
Patients Admitted w/Cervix on Adm >=4
Spontaneously Laboring Term Patients Admitted at >=4 cm):
n= 1723
N = (cervix on admission)
D = (labor type=sponteanous) + (woa >=37) + (parity CS=0)
100%
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OB COAP Aggregate
Bree Recommendation #4: Admit Spontaneously Laboring Term Patients with
Cervix on Admission >=4
Q1 - Q2 2012
Cesarean
cx on adm <=3
23%
cx on adm >=4
10%
Oxytocin
55%
cx on adm <=3
cx on adm >=4
21%
Regional Anesthesia
77%
cx on adm
<=3
56%
Length of Time Admission to Delivery <=12 Hours
73%
94%
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)
cx on adm
<=3
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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