1. Paul Gruen, Implementation Consultant
Appendix Bree Collaborative Implementation Survey Results for Medical Groups & Hospitals
Paul Gruen, Implementation Consultant

2. Purpose
This appendix contains complete results of provider surveys pertaining to implementation of Bree Collaborative topics and recommendations.
Results are reported separately for medical groups and hospitals
A concise summary of these results, along with lessons learned, conclusions, and next steps are included in the companion main presentation slides.

3. 13 Bree Collaborative Topics, 1 to 115 recommendations per topicOB
Oncology Care
Appropriate PCI
Addiction & Dependence Treatment
Cardiology- CABG
Opioid Prescriptions
Lower Back Pain
End Of Life Planning
Spine SCOAP
Hospital Readmissions
Lumbar Fusion
Knee/Hip Replacement
Prostate Cancer Screening

4. Implementation Scoring Scale
0 -No action taken 1 -Actively considering adoption 2 -Some/similar adoption 3 -Full adoption

5. Part 1: Medical Group (MG) Results
8 topics
Sorted by overall average implementation score
In order of lowest to highest (least implemented to most)
For each topic, 2 to 5 lowest scoring individual recommendations

6. 12 Medical Groups: 921 data points
Confluence Health
Providence: Pacific Medical Centers
The Everett Clinic
Providence Medical Group: SE Region
Evergreen Health Partners
Group Health
Swedish Medical Group
Multicare
Vancouver Clinic
Northwest Physicians Network
Virginia Mason
Polyclinic

7. MG #1: Addiction & Dependence Treatment (Average Score: 1.41)

8. MG #1: Addiction & Dependence Treatment (lowest scoring recommendations)
Verbal communication takes place with the chemical dependency treatment facility to follow-up on any referrals and assess whether treatment was initiated and/or completed (0.78)
The patient’s perspective is included as work is done to increase the capability of the chemical dependency system (0.78)
Patients are contacted after they have been referred to chemical dependency treatment to address any barriers to accessing treatment (0.89)
Patient results from alcohol and other drug misuse screens are tracked over time (1.00)

9. MG #2: Prostate Cancer Screening (Average Score: 1.54)

10. MG #2: Prostate Cancer Screening (lowest scoring recommendations)
Tracking of the shared decision-making process within the patient’s medical record is allowed (1.20)
Clinicians are trained on the shared decision-making process (1.54)
Patient decision aids available for PSA testing (1.50)

11. MG #3: End of Life Planning (Average Score: 1.64)

12. MG #3: End of Life Planning (lowest scoring recommendations)
All patients over the age of 18 are encouraged to consider having a conversation about advance care planning with the content of those conversations appropriate to the patient’s age, health status, literacy level, and readiness (1.10)
A durable power of attorney for health care that names a surrogate and indicates the amount of leeway the surrogate should have in decision- making, a written personal statement that articulates the patient’s values and goals regarding end-of-life care (1.40)
Standardized protocols developed on how to transfer information contained in the advance directive or POLST to hospitals in your community such as through the advance directive/POLST registry, if in existence (1.40)

13. MG #4: Low Back Pain (Average Score: 1.80)

14. MG #4: Low Back Pain (lowest scoring recommendations)
Validated screening tool like the STarT Back tool or Functional Recovery Questionnaire (FRQ) are used no later than the 3rd visit to identify patients that are not likely to respond to routine care (1.17)
Evidence-based guidelines and tools are used, including the joint American College of Physicians and American Pain Society (ACP/APS) guidelines and the Oswestry Disability Index to track functional status (1.58)

15. MG #5: Opioid Prescribing (Average Score: 1.84)

16. MG #5: Opioid Prescribing (lowest scoring recommendations)
Subacute phase (6–12 weeks): If opioids are prescribed beyond 6 weeks, PMP is rechecked and a baseline urine drug test is administered (1.40)
Perioperative Pain: Patients are evaluated thoroughly preoperatively: the PMP is checked and the patient is assessed for over-sedation and difficult-to-control pain risk (1.50)
Recognizing and treating opioid use disorder: Naloxone prescribed (especially if heroin use suspected) and patient’s contacts educated on how to use it (1.50)
All pain phases: Function and pain are assessed and documented using a validated tool at each visit where opioids are prescribed (1.50)

17. MG #6: Oncology Care (Average Score: 2.15)

18. MG #6: Oncology Care (lowest scoring recommendations)
Goals of treatment are discussed at beginning of treatment (2.09)
Oncology care is aligned with a patient’s individual goals and values and follows the American Society of Clinical Oncology’s (ASCO) position statement of key elements for individualized cancer care (2.10)

19. MG #7: Avoidable Hospital Readmissions (Average Score: 2.50)

20. MG #7: Avoidable Hospital Readmissions (lowest scoring recommendation)
Primary Care Providers have a process for providing necessary follow- up visits for discharged hospital patients who do not currently have an established PCP (1.90)

21. MG #8: Obstetrics (Average Score: 2.74)

22. Part 2: Hospital Results 16 Hospitals: 2,606 data points
CHI Franciscan Health
Swedish
Highline Medical Center
First Hill
St. Elizabeth Hospital
Cherry Hill
St. Francis Hospital
Ballard
St. Joseph Medical Center
Edmonds
Harrison Medical Center
Issaquah
Confluence Health-Central Washington Hospital UW
Harborview
The Everett Clinic*
Valley Medical Center
Northwest Hospital
University of Washington Medical Center
Virginia Mason
*completed some hospital specific topics

23. Hospital Results- 3 categories
Surgery & Surgical Bundles Topics
Condition Specific Topics
Knee/Hip Joint Replacement Bundle OB
Lumbar Fusion Bundle
Lower Back Pain
CABG Bundle
Oncology
Spine SCOP
Cardiology: Appropriate PCI
General Population Topics
Prostate Cancer Screening
Addiction & Dependence Screening
Hospital Readmissions

24. Knee and Hip Replacement Surgical Bundle 12 hospitals 87 recommendations 2.31 Average Score

25. Knee and Hip Replacement Surgical Bundle (5 lowest scoring recommendations)
Cycle 2: General health questionnaire completed: Patient Reported Outcomes Measurement Information System-10/PROMIS-10 (1.17)
Cycle 2: Patient participates in Shared Decision-making with WA State- approved Decision Aid (1.42)
Cycle 2: HOOS/KOOS survey completed (1.64)
Cycle 4: Patient-reported functional outcomes are measured with KOOS/HOOS instrument (1.58)
Cycle 4: If opioid use exceeds six weeks, a formal plan is developed for opioid management (1.58)

26. Lumbar Fusion Surgical Bundle 8 hospitals 82 recommendations 1
Lumbar Fusion Surgical Bundle 8 hospitals recommendations Average Score

27. Lumbar Fusion Surgical Bundle (9 lowest scoring recommendations)
Cycle 1: Formal consultation with collaborative team led by board certified physiatrist to confirm appropriateness, adequacy, completeness, and active participation in non-surgical therapy and need for lumbar fusion; etc. … (0.88)
Cycle 1: Departures from (non-surgical therapy) standards are reviewed by the collaborative care team (0.88)
Cycle 1: A departure from (lumbar instability measurement) guidelines requires discussion and resolution by the collaborative care team as defined (1.00)

28. Lumbar Fusion Surgical Bundle (9 lowest scoring recommendations)
Cycle 1: Self reported loss function; PROMIS-10 (1.25)
Cycle 2: Patient must participate in shared decision-making validated decision aid such as those approved by Washington State (1.25)
Cycle 2: Patient must designate a personal Care Partner; patient and Care Partner must actively participate in (various)… (1.25)
Cycle 2: Patient must participate in end of life planning… (1.25)
Cycle 2: Patient agrees to participate in a registry with two years follow-up data collection (1.25)
Cycle 4: Care Partners are instructed to assist with home exercise regimen (1.25)

29. Coronary Artery Bypass Graft (CABG) Surgical Bundle 4 hospitals recommendations average score 2.15

30. CABG Surgical Bundle (10 lowest scoring recommendations)
Cycle 1: Disability documented according to the Seattle Angina Questionnaire-7 (1.00)
Cycle 2: Pre-operative plan for management of opioid dependency, if patient has taken opioids for more than three months (0.33)
Cycle 2: Patient engages in a discrete shared decision-making process with a credentialed health coach or equivalent (0.50)
Cycle 2: Validated shared decision-making aid included such as those certified by the Washington State Health Care Authority, if available (0.50)

31. CONTINUED: CABG Surgical Bundle (lowest scoring recommendations)
Cycle 2: Screens done for predictors of delirium (1.00)
Cycle 2: General health questionnaire- PROMIS-10 (0.25)
Cycle 2: Condition-specific/standard disability questionnaire: Seattle Angina Questionnaire-7 (0.75)
Cycle 4: SAQ-7 (0.33)
Cycle 4: PROMIS-10 (0.33)
Cycle 4: If opioid use exceeds six weeks, a formal plan for opioid management is developed (0.75)

32. Hospitals: Appropriate PCI / COAP (Average Score: 3.00)

33. Hospitals: Spine SCOAP (Average Score: 2.75)

34. Hospitals: OB (Average Score: 2.78)

35. Hospitals: Prostate Cancer / PSA Screening (Average Score: 2.00)

36. Hospitals: Low Back Pain (Average Score: 1.97)

37. Hospitals: Low Back Pain (Lowest Scoring Recommendation)
A validated screening tool such as the STarT Back tool or Functional Recovery Questionnaire is used no later than the third visit to identify patients that are not likely to respond to routine care (1.63)

38. Hospitals: Oncology Care (Average Score: 2.00)

39. Hospitals: Oncology Care (Lowest Scoring Recommendations)
The American Society of Clinical Oncology’s (ASCO) Choosing Wisely recommendations are followed including:
PET [positron emission tomography], CT [computed tomography] and radionuclide bone scans are not used in the staging of early prostate cancer at low risk of spreading (1.5)
PET, CT, and radionuclide bone scans are not used in the staging of early breast cancer that is at low risk of spreading (1.5)

40. Hospitals: Addiction & Dependence Treatment (Average Score: 1.41)

41. Hospitals: Addiction & Dependence Treatment (Lowest Scoring Recommendations)
All emergency room patients over age 13 are screened for alcohol and other drug misuse using a validated and scaled screening tool or pre- screen followed by a validated full screen (1.00)
Adolescents with addictions are managed collaboratively with child and adolescent addiction specialists, if available (1.09)
Staff are trained how to do a 42 CFR part 2 compliant release of information (1.30)

42. Hospitals: Prescribing Opioids (Average Score: 2.46)

43. Hospitals: Prescribing Opioids (Lowest Scoring Recommendations)
Perioperative Pain: Patient is discharged with acetaminophen, NSAIDs, or very limited supply (2–3 days) of short-acting opioids for some minor surgeries (1.17)
Perioperative Pain: Patients on chronic opioids have doses tapered to preoperative levels or lower within 6 weeks following major surgery (1.17)
Subacute Phase (6-12 weeks): If opioids are prescribed beyond 6 weeks, PMP is rechecked and a baseline urine drug test is administered (1.17)

44. Hospitals: Readmissions (Average Score: 1.63)

45. Hospitals: Readmissions (Two Recommendations)
There is participation in a hospital readmission collaborative recognized by WSHA or Qualis Health (1.35)
Washington State Hospital Association’s Care Transitions Toolkit has been adopted, as clinically appropriate (1.71)

46. Top BARRIERS to Adoption
Availability & credibility of data
Burden/ease of collecting or obtaining data
Contract partners interested in value-based purchasing
Business case- evidence of economic reward
Consensus on what constitutes quality of care

47. Top ENABLERS to Adoption
Existing organizational improvement program for minimizing errors & waste
Business case- evidence of economic reward
Consensus on what constitutes quality of care
Individual provider-level performance and feedback
Internal awareness/support of Bree Recommendations

48. Contact
Paul Gruen, MHA Implementation Consultant, Bree Collaborative Foundation for Health Care Quality 705 Second Avenue, Suite 410 | Seattle, WA (206)