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					                                       Bree Collaborative Meeting Minutes*

                                                   May 31, 2012

Members Present
Roki Chauhan, MD, Premera Blue Cross*                          Robyn Phillips-Madson, Pacific NW University of
Susie Dade, Puget Sound Health Alliance                        Health Sciences
Gary Franklin, MD, WA State Labor and Industries               Carl Olden, MD, Pacific Crest Family Medicine
Tom Fritz, Inland Northwest Health Services                    Mary Kay O’Neill, MD, CIGNA
Joe Gifford, MD, Regence Blue Shield                           John Robinson, MD, First Choice Health
Rick Goss, MD, Harborview Medical Center                       Terry Rogers, MD, Foundation for Health Care
Mary Gregg, MD, Swedish Medical Center                         Quality (FHCQ)
Anthony Haftel, MD, Franciscan Health Systems                  Eric Rose, MD, Fremont Family Medical
Steve Hill, Bree Collaborative Chair                           Kerry Schaefer, King County
Jodi Joyce, RN, Legacy Health                                  Bruce Smith, MD, Group Health Cooperative
Theresa Helle, The Boeing Company (for Greg                    Jeff Thompson, MD, WA Health Care Authority
Marchand)                                                      Peter Valenzuela, MD , PeaceHealth
Robert Mecklenburg, MD, Virginia Mason Medical
Center

Absent
Stuart Freed, MD, Wenatchee Valley Medical Center
Jay Tihinen, Costco

Staff/Guests
Jane Beyer, WA House Democratic Caucus                         Bob Perna, WSMA
Vergil Cabasco, WSHA                                           Rachel Quinn, Bree Collaborative
Jim Cannon, Providence Health & Services                       Patti Rathbun, WA Dept of Health*
David Hanig, WA Senate Democratic Caucus                       Claudia Sanders, WSHA
Leah Hole-Curry, WA State Labor and Industries                 Kristin Sitcov, FHCQ
Ellen Kauffman, MD, FHCQ                                       Julie Sylvester, Qualis Health
Marie Manteuffel , WA State Labor and Industries               Michael Vanderlinde, Harborview
Jason McGill, Governor’s Office

*by phone

Steve Hill, Bree Collaborative chair, called the meeting to order. In his opening remarks he referred to a letter
dated April 22, 2012 he received from Scott Bond and Tom Curry, the presidents of the Washington State
Hospital Association (WSHA) Washington State Medical Association (WSMA), respectively (a copy of the letter
was shared with Bree Collaborative members via email). The letter outlined their organizations’ concerns and
recommendations to make the Bree Collaborative processes more transparent. Mr. Hill met with Mr. Bond and
Mr. Curry and re-pledged his commitment to transparency and inclusiveness of all stakeholders in all processes.
Bree Collaborative members were given an opportunity for comments; no one had comments.

Mr. Hill presented an opportunity for public comment. Rachel Quinn, Bree project manager, shared that WSHA
provided a written report summarizing accomplishments and actions of their elective deliveries 37 to 39 weeks
initiative (copies of the report were distributed to Bree Collaborative members).

Mr. Hill disclosed he is on the boards of the Leapfrog Group and Consumers Union.

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* Minutes adopted by the Bree Collaborative at its August 2 meeting.
Obstetrics Topic – Review of OB Report
Rachel Quinn, Bree Collaborative project manager, presented the current draft of the Obstetrics (OB) report
(See Bree website for a copy of the PowerPoint presentation and report). The purpose of the presentation was
to walk Bree Collaborative members through the different sections of the report and discuss specific sections
where Bree Collaborative members had questions. The intended action at the end of the presentation was for
Bree Collaborative members to adopt the report.

Report Section - OB Areas of Focus and Goals

Bree Collaborative discussed the OB subgroup’s primary C-section goal. Most hospitals currently use the
nationally accepted NTSV C-section measure to measure variation in C-section rates, because no national
primary C-section measure exists. Some Bree Collaborative members had concerns about being asked to collect
data on another quality measure (primary C-section) given that hospitals’ resources are constrained; Theresa
Helle from Boeing said it was important and hospitals should invest in resources necessary to provide good data
and make data transparent. All agreed the primary C-section rate goal is a good goal; and could be achieved in
time and hopefully without great expense. Another Bree Collaborative member asked how the Bree
Collaborative’s focus areas and goals align with other current maternity efforts. The Bree Collaborative’s OB
focus areas and goals are in alignment and complement other local and national maternity efforts. Some
discussion about the “hard-stop” recommendation concluded with agreement that it is an appropriate
scheduling policy unless there’s a documented clinical reason.

A motion was made (Joyce), seconded (Olden), and approved to accept the three focus areas and goals as
stated in the report distributed at the meeting (listed below):

1. Elective Deliveries. Eliminate all elective deliveries before the 39th week (those deliveries for which there
   is no documentation of medical necessity).
       Proven quality improvement strategies exist to meet this goal.
       Goal builds upon the great work of existing local and national initiatives to reduce elective deliveries
        before the 39th week (The Leapfrog Group has set a national target of 5%; the Washington Perinatal
        Collaborative and partners have set a target of less than 5%; and the Institute for Healthcare
        Improvement has a target of zero).
       The Bree believes no elective deliveries should occur.
2. Elective Inductions of Labor. Decrease elective inductions of labor between 39 and up to 41 weeks.
       Proven quality improvement strategies exist to meet this goal.
       Decreasing elective inductions will decrease the primary C-section rate.
3. Primary C-sections. Decrease unsupported variation among Washington hospitals in the primary C-section
   rate.
       Decreasing the unsupported variation of primary C-section rates is necessary in order to make a
        significant impact on outcome and cost.
       Focusing on decreasing primary C-sections as a goal casts a wide net and will have a broad effect,
        thereby decreasing the C-section rate in different populations (e.g., NTSV C-section).
       Decreasing primary C-sections also prevents repeat C-sections and poor pregnancy outcomes resulting
        from accumulating C-section scars, such as placenta previa, preterm birth, and placenta accreta.

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* Minutes adopted by the Bree Collaborative at its August 2 meeting.
Report Section - Recommendations: Quality Improvement Strategies and Actions section

Bree Collaborative discussed recommendations and recommended changes to the hospital and employer
recommendations:

       Hospital recommendations - There was discussion that the report should stress that the labor and
        delivery guidelines are a “place to start” until alternatives or equally rigorously tested guidelines are
        developed. Some Bree Collaborative members suggested asking experts to review and comment on the
        Bree’s recommended guidelines for induction and labor and delivery management guidelines for C-
        sections.

A motion was made (Smith), seconded (Dade), and approved to accept the hospital recommendations with
the following changes listed below) (there also were some minor, editorial changes).

       Employer recommendations -Bree Collaborative members recommended the following changes:

            o   Add “purchasers” to the current name of the “employer recommendations;”

            o   Change first bullet to: Work in conjunction with health plans or third party administrator to
                make benefit design changes that support evidence-based care and reward better outcomes.”

After the discussion on the recommend actions, a motion was made (Dade), seconded (Joyce), and approved
to accept the OB report with the changes discussed, and give authority to the Bree Collaborative steering
committee to approve the changes necessary and discuss next steps about an implementation plan.

Some discussion occurred about implementing the report. Olden mentioned that at the annual Washington
State Obstetrical Association (WSOA) meeting, at the end of the year, he plans to present and ask the WSOA to
endorse the recommended actions.

Cardiac
Dr. Chris Bryson, COAP medical director, gave an update on the Bree Collaborative’s request to unblind COAP
data on appropriate use of percutaneous coronary interventions (PCI). To recap, the COAP Management
Committee in February approved the Bree Collaborative’s request to ask member hospitals to share un-blinded
results publically, including facility-level results and the clear identification of missing documentation. (Right
now, COAP data is currently confidential and shared in an un-blinded manner but with hospitals that are
participating in COAP only).

Dr. Bryson presented 2011 COAP data on appropriate use of percuaneous coronary interventions (PCIs) and
insufficient information, the same data he presented at a breakout session on this issue at the COAP annual
meeting on May 14th. Bree Collaborative members and community representatives (Joe Gifford, Regence;
Theresa Helle, The Boeing Company; Mary McWilliams, the Puget Sound Health Alliance) attended the breakout
session and stressed the need for transparency of the COAP data.

In terms of next steps, Dr. Bryson proposed the Bree Collaborative send a letter to the COAP Management
Committee proposing a four-step process to post COAP publically:

1) An appropriate use insufficient information report, by hospital, will be posted on the COAP members-only
   section of the website.


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* Minutes adopted by the Bree Collaborative at its August 2 meeting.
2) COAP will provide feedback to hospitals and provide tools for reducing the amount of insufficient
   information in their data.
3) The Bree collaborative will receive a copy of the report. Hospitals will have the option to not be identified.
4) Once hospitals have been given a chance to employ methods for improvement, reports will begin being
   posted on the public section of the website. Hospitals will again have the option to not be identified.
A motion was made (Olden), seconded (Dade), and approved to allow the Bree Collaborative staff to move
ahead and send a letter to the COAP management committee with the four steps outlined above.

Readmissions
Steve Hill presented the charter for the readmissions workgroup. A discussion ensued about deleting
“unnecessary” before readmissions, and the three strategies listed at the top of the charter. Some Bree
Collaborative members had concerns about endorsing the second strategy, a payment reform pilot, before an
official root-cause analysis has been conducted. Some Bree Collaborative members believe payment reform
might not be a necessary strategy to reduce readmissions. It was also noted that process measures might be a
potential strategy, too. Mr. Hill said additional representatives are needed to serve on the readmissions
workgroup, so he asked for volunteers. Mary Gregg, Ton Haftel, and Tom Fritz volunteered for the workgroup.

A motion was made (Rogers), seconded (Franklin), and approved to change “unnecessary readmissions” to
“potentially avoidable readmissions,” allow the chair to add more experts to the readmission committee, and
amend the three strategies on the readmissions charter to be:

1) Endorsement and coordination of evidence-based, quality improvement initiatives aimed at reducing
   potentially avoidable readmissions, including continuity of care across the continuum;
2) Investigation of current process measures for reducing potentially avoidable readmissions and a potential
   bundled payment structure; and
3) Transparency of readmissions rates, by hospital and physician group, in a semi-public manner.

A Bree Collaborative member was confused by the different roles of the readmissions subcommittee and the
readmissions payment reform subgroup. Even though the readmissions payment reform subgroup would report
to the readmissions subcommittee, there is some risk the payment reform subgroup could get ahead of the
readmissions subcommittee (since they are meeting at the same time). A Bree Collaborative member suggested
that readmissions is a big topic, Group Health Cooperative has 7 readmissions subgroups, and that the
readmission subcommittee should meet first before forming subgroups. Given the discussion, the Bree
Collaborative did not review the charter for the readmissions payment reform subgroup.

A motion was made (Franklin), seconded (Phillips-Madson), and approved not to form a readmissions
payment reform subgroup at this time.

Lumbar Spinal Fusion
At the last Bree Collaborative meeting in March, the Bree Collaborative agreed to continue monitoring the spine
fusion issue, and for Dr. Franklin to keep the Bree Collaborative abreast of new developments.

Steve Hill asked for volunteers to study this issue and bring back a plan for the Bree Collaborative to consider at
its next meeting. Gary Franklin, Terry Rogers, Bob Mecklenburg, John Robinson, and Mary Kay O’Neill
volunteered to work on a proposed plan.



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* Minutes adopted by the Bree Collaborative at its August 2 meeting.
New Business/Good of the Order
Steve Hill allowed another opportunity for discussion on the WSHA/WSMA letter. No discussion ensued.

Steve Hill allowed an opportunity for public comment. Jason McGill, Policy Advisor to Governor Gregoire,
congratulated the group on their hard work and for approving the OB report.

Steve Hill pointed out to the group the recent “Choosing Wisely” campaign, created to help reduce waste in the
US health care system and promote physician and patient conversations about making wise decisions about
treatments. Nine medical specialties have joined the ABIM (American Board of Internal Medicine) Foundation
and Consumer Reports in the first phase of the campaign. Each specialty published a list of tests, treatments, or
services that are commonly used in that specialty and for which the use should be re-evaluated by patients and
clinicians. Obstetrics is rumored to be working on publishing a list for the “Choosing Wisely” campaign, to be
published in the fall.

Leah Hole-Curry announced a federal funding opportunity available through PCORI (Patient-Centered Outcomes
Research Institute), a non-profit organization created by Congress in 2010 to fund evidence-based research.
PCORI has released its first primary research funding announcements to support comparative clinical
effectiveness research that will give patients and those who care for them the ability to make better-informed
health care decisions. All application materials can be downloaded from the Funding Opportunities section of
PCORI’s website.

The next Bree Collaborative meeting will be held in approximately six weeks.




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* Minutes adopted by the Bree Collaborative at its August 2 meeting.

				
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