The Bree Collaborative · Web view2016/08/03 · VII.Lumbar Fusion Surgical Bundle (4 items + 78 conditional) VIII. Total Knee/Hip Replacement Surgical Bundle (4 items + 81 conditional)

www.breecollaborative.org

Submit Responses via Email to: Paul Gruen, Implementation ConsultantBree [email protected]

Implementation Survey: Hospitals

INTRODUCTIONIn 2011, the Washington State Legislature established the Dr. Robert Bree Collaborative so that public and private health care stakeholders would have the opportunity to identify specific ways to improve health care quality, outcomes, and affordability in Washington State. These stakeholders are appointed by the Governor as Collaborative members and represent public health care purchasers for Washington State, private health care purchasers (employers and union trusts), health plans, physicians and other health care providers, hospitals, and quality improvement organizations.

Work groups review evidence-based guidelines and seek consensus from the Collaborative on selected topics. Recommendations are sent to the Washington State Health Care Authority for approval, in order to guide the type of health care provided to Medicaid enrollees, state employees, and other groups. Other healthcare purchasers and providers are encouraged to adopt recommendations into their own operations and reimbursement contracts where appropriate.

We are currently working to measure and facilitate adoption of our recommendations across Washington State. This survey is meant to assess adoption of our recommendations by hospitals.

SCALEWe are measuring adoption of specific recommendations using 0-3 point scale, self-assessed by each hospital

0 - No action taken No leadership awareness of Bree Collaborative Topics No team formed 1 - Actively considering adoption Bree topics, aims and components have been discussed Education, assessment, information gathering Changes planned but not tested Information gathering and baseline measurement begun 2 - Some/similar adoption Initial test cycles completed for more than one element

Quality metrics and data available demonstrating

adoption/effectiveness Other similar (Bree-like) changes adopted for this topic

3 - Full adoption Changes implemented in all areas All components integrated into care process (i.e. orders, etc.)

Partial or complete closure of gap between baseline & target

outcomes

RESULTS Results will be collected, compiled and shared with responding hospitals, Bree Collaborative members, workgroup members, and others in Washington State.

mailto:[email protected]

http://www.breecollaborative.org/

Implementation Survey OutlineBree Collaborative

I. Organization Information

II. Obstetrics Care (15 items)

III. Cardiology: Appropriate Percutaneous Coronary Intervention (2 items)

IV. Coronary Artery Bypass Graft Bundle (excluding urgent or emergent) (4 items + 115 conditional)

V. Low Back Pain (4 items)

VI. Spine Surgical Care and Outcomes Program (SCOAP) Participation (1 item)

VII. Lumbar Fusion Surgical Bundle (4 items + 78 conditional)

VIII. Total Knee/Hip Replacement Surgical Bundle (4 items + 81 conditional)

IX. Prostate Cancer Screening (2 items)

X. Oncology Care (6 items)

XI. Addiction and Dependence Treatment (11 items)

XII. Prescribing Opioids for Pain (17)

XIII. End of Life Planning (16 items)

XIV. Potentially Avoidable Hospital Readmissions (2 items)

XV. Factors Affecting Adoption (Barriers/Enablers)

I. Your Organization

Name of Hospital:

Person Completing Survey:

Title:

Phone:

Email:

II. Obstetrics Care

Read the full report here: www.breecollaborative.org/wp-content/uploads/bree_ob_report_final_080212.pdf

0 -No action taken; 1 -Actively considering adoption; 2 -Some/similar adoption; 3 -Full adoption

SCORE

Obstetrics quality improvement program is in place

Policy is in place that limits deliveries before the 39th week that includes:

- If induction between 37 and 39 weeks occurs, indication was on the Joint Commission or Washington State Perinatal Collaborative/WSHA project list

- For clinical situations not on the two lists above, consultation occurs and agreement is obtained that the clinical situation required delivery

- Data, including baseline, on early elective delivery is collected

Policy for scheduling inductions between 39-41 weeks includes:

- The cervix is favorable (Bishop score of 6 or greater)

- A consent form specific to the risk and benefits of induced compared with spontaneous labor has been signed by the patient

- Data, including baseline, on elective inductions is collected

Policy for Cesarean-Sections includes:

- Admitting only spontaneously laboring women at term who present with no fetal or maternal compromise when the cervix is 4 centimeters or more dilated

- Allowing 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)

http://www.breecollaborative.org/wp-content/uploads/bree_ob_report_final_080212.pdf

- Allowing adequate time in the active phase (4 to 6 hours) with use of appropriate clinical interventions before making a diagnosis of active phase arrest

- Allowing sufficient time with appropriate clinical interventions in the 2nd stage before diagnosis of 2nd stage arrest or “failure to descend”

- Data on C-sections, including baseline, is collected

Data and feedback are provided to clinicians

Public reporting on obstetrics procedure data (through existing website such as WSHA) is supported

Patients are provided with education and shared decision-making on maternity care options and risks of pre-term births, elective deliveries, and C-sections

Additional Comments:

III. Cardiology: Appropriate Percutaneous Coronary Intervention (PCI)

Read the full report here: http://www.breecollaborative.org/wp-content/uploads/bree_bc_cardiology_final.pdf


SCORE

Hospital participates in the Clinical Outcomes Assessment Program (COAP, www.coap.org)

Appropriateness of percutaneous coronary intervention is measured and reported to COAP using the American College of Cardiology’s Appropriate Use Criteria

Results are allowed to be transparently published with the COAP program


http://www.coap.org/

http://www.breecollaborative.org/wp-content/uploads/bree_bc_cardiology_final.pdf

IV. Coronary Artery Bypass Graft Bundle (excluding urgent or emergent)

Read the full report here: http://www.breecollaborative.org/wp-content/uploads/CABG-Bundle-Final-15-09.pdf


SCORE

IF YOU ANSWER 2 OR 3 ON ANY OF THE FOLLOWING FOUR PARTS (PARTS I – IV), PROCEED TO THE DETAIL SECTION OF THAT CORRESPONDING PART. OTHERWISE, IF ANSWERING 0 OR 1, YOU MAY SKIP.

PART I: Bree recommendations are followed for ensuring disability despite non-surgical therapy

PART II: Bree recommendations are followed for ensuring fitness for surgery

PART III: Bree recommendations are followed for CABG procedure

PART IV: Bree recommendations are followed for post-operative care and return to function


I: DISABILITY DESPITE NON-SURGICAL THERAPY

A) Document disability

1. Grade of angina (I-IV) documented according to Canadian Cardiovascular Society grade of angina pectoris

2. Disability documented according to the Seattle Angina Questionnaire-7

3. Self-reported loss of function documented with Patient Reported Outcomes Measurement Information System-10® (PROMIS-10)

B) Myocardial ischemia documented with appropriate non-invasive stress testing according to 2012 ACCF, et.al. Guidelines & 2014 Guidelines Focused Update

C) Risk factor modification begun according to ACCF Guideline above unless need for urgent intervention

1. Patient education begun with a goal of empowering and improving participation in shared decision-making

2. Cardiac diet begun or maintained, with attention to:

http://www.breecollaborative.org/wp-content/uploads/CABG-Bundle-Final-15-09.pdf

a) Weight management to maintain or achieve a BMI between 18.5 and 24.9 kg/m2;

b) Blood pressure management;

c) Lipid management

3. Appropriate physical activity advised:

a) Estimate risk of physical activity;

b) 30-60 minutes moderate-intensity activity recommended daily for low risk patients;

c) Medically supervised exercise considered for higher-risk patients

4. Overuse of alcohol screened and manage if needed

5. Patient assisted with smoking cessation if needed

6. Diabetes managed with target HbA1c between 7-9% depending on risk/benefit

7. Depression screened and treated if positive

8. Stress management considered and assistance given if indicated

9. Dementia screened and managed as necessary if positive

10. Immunize against influenza annually

11. Statin medication prescribed unless contraindicated

12. Blood pressure managed according to March 2015 guideline update from AHA/ACC/AHS, including anti-hypertensive drugs for BP above guideline goals

13. Antiplatelet therapy prescribed unless contraindicated

14. Beta blocker therapy prescribed unless contraindicated

15. Renin-angiotensin-aldosterone blocker therapy prescribed, per ACCF Guideline

16. Anti-anginal therapy prescribed as tolerated, with two or more of the following agents as needed: a) Beta blockers; b) Calcium channel blockers when beta blockers are contraindicated or unsuccessful; c) Long acting nitrates; d) Ranolazine

D) Patients stratified prior to determining appropriate intervention

1. Multidisciplinary Heart Team approach used in decision making for patients with complex coronary artery disease composed of an interventional cardiologist, a cardiac surgeon, and other consultants, as needed

2. Interventions based on the 2012 ACCF Guidelines (http://content.onlinejacc.org/article.aspx?articleid=1201161 )

3. STS score used to assist with decision for intervention

4. Additional factors considered such as left main disease, diabetes with multi-vessel disease, and severity of symptoms related to ischemia

http://content.onlinejacc.org/article.aspx?articleid=1201161

II: FITNESS FOR SURGERY

A) Requirements documented related to patient safety (if compatible)

1. Body Mass Index less than 40

2. Hemoglobin A1c less than 8% in patients with diabetes

3. Adequate nutritional status to ensure healing

4. Sufficient liver function to ensure healing

5. Pre-operative plan for management of opioid dependency, if patient has taken opioids for more than three months

6. Avoidance of smoking for at least four weeks pre-operatively

7. Alcohol abuse screened for with management plan if screen is positive

8. Depression screened for with management plan if positive

9. Dementia screened for with management plan if positive

10. Pre-operative plan developed for post-operative return to function

11. Risk for co-occurring cerebrovascular disease assessed; including imaging carotid circulation (ultrasound or MRA) for clinically high-risk patients

a) Patients with high-risk carotid arterial disease treated according to ACC/AHA guidelines, 2012

B) Patient engagement documented

1. Patient participates actively in shared decision-making with full knowledge of risks, benefits, alternatives, and preferences; this requirement is in addition to informed consent

a) Patient engages in a discrete shared decision-making process with a credentialed health coach or equivalent

b) Validated shared decision-making aid included such as those certified by the Washington State Health Care Authority, if available

c) During this encounter, the patient and coach addresses:

i. Issues related to an active, life-limiting condition that would likely cause death before recovery from surgery

ii. Disability from an unrelated condition that would severely limit the benefits of surgery

iii. Dementia that would interfere with recovery from surgery; performing surgery on a patient with such dementia requires preauthorization, informed consent of a person with durable power of attorney for health care, and a contract with the patient’s care partner regarding accountability for care aligned with the patient’s care plan and made available to the purchaser

iv. For patients 65 years and older, the ASCERT calculator may be used to

assess likelihood of survival from CABG

d) Patient’s preference documented for treatment as part of this encounter

2. Patient designates a personal care partner; patient and care partner actively participate in the following:

a) Surgical consultation

b) Pre-operative evaluation

c) Pre-surgical class and/or required surgical and anesthesia educational programs

d) In-hospital care

e) Post-operative care teaching patients home care and exercise program

f) Assessment of home-based physical and psychosocial hazards that may interfere with recovery

3. End-of-life planning offered to patient, including completion of an advance directive, designation of durable power of attorney for health care, and participation in an option for organ donation

4. Patient encouraged to participate in the COAP registry with two years follow-up data collection

C) Optimal preparation for surgery documented

1. Pre-operative history, physical, and screening lab tests performed based on review of systems:

a) Pulmonary fitness evaluated;

b) Basic lab profile, plasma glucose, prothrombin time, complete blood count, urinalysis with culture, obtained if indicated;

c) Nasal passages cultured to identify staphylococcal carrier state and treat accordingly;

d) Screens done for predictors of delirium

2. Relevant consultations obtained:

a) Evaluating for good dental hygiene in high-risk patients;

b) Referrals are made to Anesthesia for pre-operative assessment including identification and management of conditions such as sleep apnea and pulmonary hypertension;

c) Other consultations requested, as necessary

3. Post-operative care plan reviewed, including cardiac rehabilitation

4. Patient started or continued on statin therapy (unless contraindicated) according to current guidelines

5. Beta-blocker administered during the perioperative period for all patients on

beta-blocker therapy prior to surgery

6. Beta blockers administered at least 24-hours before CABG to all patients without contraindications to reduce the incidence of complications of post-operative atrial fibrillation

7. Aspirin begun or continued unless contraindicated

8. Patient-reported measures collected to confirm lack of significant response to non-surgical treatments using:

a) General health questionnaire PROMIS-10;

b) Condition-specific/standard disability questionnaire: Seattle Angina Questionnaire-7

III. CABG PROCEDURE

“2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery” guideline followed or more recent if possible:

http://circ.ahajournals.org/content/124/23/e652.full.pdf+html

A) General standards for a surgical team performing surgery

1. Cardiac surgeons board certified or board eligible by the American Board of Thoracic Surgery or certified by a reciprocal and equivalent credentialing organization

2. Surgeon outcome metrics are within two standard deviations, away from the desired direction, of the community standard (e.g., mean) of the Clinical Outcome Assessment Program (COAP) Level I quality indicators; these include: mortality, post-operative stroke, and renal insufficiency requiring dialysis based on at least 25 open heart surgeries (elective and urgent) to ensure statistical reliability

3. Members of the surgical team have documented credentials, training, and experience

4. Consistency ensured in roster of the surgical team

5. Surgery performed in an inpatient facility

6. Policies aligned with the American College of Surgeons Statement on Health Care Industry Representatives in the Operating Room in facilities in which surgery is performed

B) Elements of optimal surgical process

1. Pain management and anesthesia optimized:

a) Anesthesia management format used to minimize sedation and encourage early extubation and recovery;

b) Use of opioids minimized and prescribed according to Washington State Agency Medical Director’s Group Opioid Prescribing Guidelines, 2015 Interagency Guidelines or more recent if available

http://circ.ahajournals.org/content/124/23/e652.full.pdf+html

2. Infection avoided:

a) Appropriate peri-operative course of antibiotics administered according to guidelines set forth in the Surgical Care Improvement Project (SCIP): SCIP-Inf-1b, 2b, 3b; CMS Measure 1, 2, 3;

b) Urinary catheter use restricted to less than 48 hours per SCIP guidelines: SCIP-Inf-9;

c) Appropriate method for hair removal used, shaving avoided: SCIP-Inf-6;

d) Appropriate skin prep used by patient prior to surgery

3. Bleeding and low blood pressure avoided:

a) Standardized protocols administered using appropriate medications to limit blood loss;

b) Institution-based standard IV fluid and inotrope protocols used including those implemented by RNs post-operatively with appropriate supervision and monitoring

4. Deep venous thrombosis and embolism avoided according to guidelines set forth in the SCIP VTE-2, CMS Measure 4

5. Avoiding hyperglycemia: Standardized protocol used to maintain optimal glucose control, SCIP-Inf-4

6. Perioperative temperature managed, SCIP-Inf-10

C) Participation in registries

1. Participating in the Washington State Clinical Outcomes Assessment Program (COAP) for cardiovascular surgery

IV. POST-OPERATIVE CARE AND RETURN TO FUNCTION

A) Standard process for post-operative care

1. A rapid and durable recovery track utilized to mobilize patients following surgery:

a) Cardiac rehabilitation provided, including early ambulation during hospitalization, outpatient prescriptive exercise training, and education;

b) Patient-oriented visual cue provided to record progress on functional milestones required for discharge;

c) Risk factor modification reinforced;

d) Care Partner instructed to assist with home care

2. Access provided to hospitalists or appropriate medical consultants for consultation to assist with complex or unstable medical problems in the post-operative period

3. Post-operative nursing and rehabilitative needs addressed for patients that meet Medicare standards and will be discharged to a skilled nursing facility

4. Follow-up call scheduled by the surgical team to patient and family 24 to 48 hours and seven days post discharge.

B) Standardized hospital discharge process used, aligned with Washington State Hospital Association (WSHA) toolkit

1. Follow up arranged with outpatient care team according to WSHA toolkit

2. Social and resource barriers evaluated based on WSHA toolkit

3. Smoking cessation program continued for previous nicotine users

4. Medications reconciled to ensure essential medications are started or continued:

a) Anti-platelet medication: CMS Measure 10;

b) Statins;

c) Aspirin

5. Patient and family/caregiver education provided with plan of care:

a) Signs or symptoms that warrant follow-up with provider;

b) Guidelines for emergency care and alternatives to emergency care;

c) Contact information for cardiac care team and primary care provider

6. Post-discharge phone call ensured to patient by care team to check progress, with timing of call aligned with WSHA toolkit

7. Hospital discharge kit provided upon discharge according to WSHA toolkit

C) Home care arranged

1. Patient and care partner provided with information regarding home care

2. Additional home health services arranged as necessary

D) Post-operative care arranged

1. Post-discharge summary sent to primary care provider within three business days of discharge

2. Cardiac rehab scheduled to be managed as clinically appropriate

3. Follow up appointments scheduled as appropriate

4. Patient-reported functional outcomes measured with standard instrument at three months:

a) SAQ-7;

b) PROMIS-10.

5. If opioid use exceeds six weeks, a formal plan for opioid management is developed


V. Low Back Pain

Read the full report here: http://www.breecollaborative.org/wp-content/uploads/spine_lbp.pdf


COMPONENT ASSESSMENT SCORE

A low back pain quality improvement program that includes measuring patients’ functional status over time using the Oswestry Disability Index is supported or sustained

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

Evidence-based guidelines, scripts, shared decision making, and patient education materials are integrated into clinical practice and workflow (e.g., electronic medical record, a clinical decision support tool such as UpToDate, etc.)

Comprehensive patient education and effective messaging are integrated into clinical practice and workflow for low back pain patients


VI. Spine Surgical Care and Outcomes Program (SCOAP) Participation

Read the endorsement here: http://www.breecollaborative.org/wp-content/uploads/bree_bc_spine_scoap_rec.pdf and revision here: http://www.breecollaborative.org/wp-content/uploads/spine_scoap_recommendation.pdf

http://www.breecollaborative.org/wp-content/uploads/spine_scoap_recommendation.pdf

http://www.breecollaborative.org/wp-content/uploads/bree_bc_spine_scoap_rec.pdf

http://www.breecollaborative.org/wp-content/uploads/spine_lbp.pdf


ASSESSMENT SCORE

Hospital participates in the Spine Surgical Care and Outcomes Assessment (SCOAP) program (www.scoap.org)


VII. Lumbar Fusion Surgical Bundle

Read the full report here: http://www.breecollaborative.org/wp-content/uploads/Lumbar-Fusion-Bundle-Final-14-09.pdf


ASSESSMENT SCORE


PART I: Bree recommendations are followed for ensuring disability despite non-surgical therapy


PART III: Bree recommendations are followed for spinal fusion procedure



I. DISABILITY DESPITE NON-SURGICAL THERAPY

http://www.breecollaborative.org/wp-content/uploads/Lumbar-Fusion-Bundle-Final-14-09.pdf

http://www.scoap.org/

A) Documentation made of disability due to either neurologic symptoms and/or signs of back pain with without neurological findings

1. Disability according to standard outcome score: Oswestry Disability Index (ODI) documented

2. Self-reported loss of function documented with Patient Reported Outcome Measuring System-10® (PROMIS-10®) or other validated scale

3. Standardized baseline physical function documented by physical therapist using the Therapeutic Associates Outcome Score

B) Documentation made of imaging findings of lumbar instability on a standard scale that correlates with symptoms and signs

1. Adequate standing flexion/extension views are taken utilizing techniques that minimize the potential contribution of hip motion to perceived lumbar flexion or extension

2. At least 4mm of anterior/posterior translation at L3-4 and L4-5, or 5mm of translation at L5-S1 or 11 degrees greater end plate angular change at a single level, compared to an adjacent level

3. A departure from these guidelines requires discussion and resolution by the collaborative care team as defined below

C) Documentation made of at least three months of structured non-surgical therapy, as delivered by a collaborative team (a physiatrist, an appropriate spine surgeon, the primary care provider, physical therapist, care partner, and others as needed)

1. Trial of the following non-surgical measures conducted: a) Patient education; b) Active physical therapy; c) Behavioral therapies aimed at improving self-efficacy with an emphasis on effectively addressing important psychosocial elements such as fear avoidance, catastrophizing, and low expectations of recovery; d) Identification and management of associated anxiety and depression

2. Trial of one or more of the following medications conducted if not contraindicated: a) Acetaminophen; b) Oral non-steroidal anti-inflammatory drugs; c) Tricyclic antidepressants; d) Other appropriate and evidence-based medications, as indicated

3. Spinal manipulation or other evidence-based non-surgical therapies used at the discretion of the collaborative care team

D) Documentation of persistent disability despite non-surgical therapy

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; at least two of the following should be considered in defining persistent disability: a) Greater than 20% disability as defined by the Oswestry Disability Index; b) Persistent disability according to PROMIS indicators; c) Persistent disability on baseline physical function by physical therapist using the Therapeutic Associates Outcome Score,

defined as equal to or greater than 20% disability

2. Confirmation made that the degree and location of pain and/or physical impairment matches the anatomic location of imaging abnormalities

3. Departures from these standards are reviewed by the collaborative care team

II. FITNESS FOR SURGERY

A) Documentation of requirements related to patient safety

Patient should meet the following minimum requirements prior to surgery:

1. Body Mass Index less than 40

2. Hemoglobin A1c less than 8% in patients with diabetes

3. Adequate nutritional status to ensure healing

4. Sufficient liver function to ensure healing

5. Pre-operative plan for management of opioid dependency, if patient has taken opioids for more than three months

6. Avoidance of smoking for a minimum of four weeks pre-operatively with six to eight weeks preferred

7. Screen for alcohol abuse; manage if screen is positive

8. Absence of an active, life-limiting condition that would likely cause death before recovery from surgery

9. Absence of severe disability from an unrelated condition that would severely limit the benefits of surgery such as severe osteoporosis

10. Absence of dementia that would interfere with recovery – performing surgery for a patient with such dementia requires preauthorization, informed consent of a person with Durable Power of Attorney for Health Care, and a contract with the patient’s care provider

11. Screen for untreated depression or psychiatric disorder; manage if screen is positive

12. Complete a pre-operative plan for post-operative return to function

13. Screen for osteoporosis in high-risk individuals; manage if screen is positive

B) Documentation of patient engagement

1. Patient must participate in shared decision-making validated decision aid such as those approved by Washington State; this requirement is in addition to informed consent

2. Patient must designate a personal Care Partner; patient and Care Partner must actively participate in the following: a) Surgical consultation; b) Pre-operative evaluation; c) Pre-surgical class and/or required surgical and anesthesia educational programs; d) In-hospital care; e) Post-operative care teaching; f) Patient’s home care and exercise program

3. Patient must participate in end of life planning, including completion of an advance directive and designation of durable power of attorney for health care

4. Patient agrees to participate in a registry with two years follow-up data collection

C) Documentation of optimal preparation for surgery

1. Pre-operative history, physical, and screening lab tests performed based on review of systems:

a) Cardiac and pulmonary fitness evaluated;

b) Basic lab profile, plasma glucose, prothrombin time, complete blood count, and/or urinalysis with culture obtained, if indicated;

c) Nasal passages cultured to identify staphylococcal carrier state;

d) A1c less than 8% ensured in patients with diabetes;

e) Relevant imaging performed if not performed within previous six months;

f) Predictors of delirium screened for

2. Relevant consultations obtained:

a) Good dental hygiene evaluated for with dental consultation as necessary;

b) Anesthesia referred to for pre-operative assessment including identification and management of such conditions such as sleep apnea and pulmonary hypertension;

c) Physical therapist(s) consulted to instruct in improving return to function;

d) Additional consults requested as necessary

3. Patient-reported measures collected to confirm lack of significant response to nonsurgical treatments using:

a) General health questionnaire: PROMIS-10 collected;

b) Standardized disability survey: ODI collected

III. SPINAL FUSION PROCEDURE

A) General standards for a surgical team performing surgery followed:

1. The spine surgeon has performed a minimum of twenty lumbar fusion surgeries in the previous twelve months; neurosurgeons are board certified or board eligible; orthopedic surgeons have successfully completed a spine fellowship

2. Members of the surgical team have documented credentials, training, and experience; the roster of the surgical team is consistent

3. Surgical team may include two attending surgeons to reduce anesthesia time and blood loss particularly in complex cases

4. Elective spine surgery is scheduled to begin before 5:00 pm

5. Surgery is performed in an inpatient facility

6. Facilities in which surgery is performed have policies that align with the American College of Surgeons Statement on Health Care Industry Representatives in the Operating Room



a) Multimodal pain management format used to minimize sedation and encourage early ambulation

b) Use of opioids minimized


a) Appropriate peri-operative course of antibiotics administered according to guidelines set forth in the Surgical Care Improvement Project (SCIP);

b) Use of urinary catheter restricted to less than 48 hours per SCIP guidelines;

c) Chlorhexidine skin prep used by patient prior to surgery if no contraindication



b) Standardized IV fluid protocols used including those implemented by RNs postoperatively with appropriate supervision and monitoring.

4. Deep venous thrombosis and embolism avoided according to guidelines set forth in the SCIP

5. Hyperglycemia avoided: Standardized protocol used to maintain optimal glucose control

6. Bone morphogenic protein: If bone morphogenic protein is used it is in accordance with Washington Health Technology Program policy: http://www.hca.wa.gov/hta/Documents/findings_decision_bmp.pdf

C) Participation in registries

1. Hospital participates in the Spine SCOAP registry with results available to purchasers

2. Providers maintain a registry of patients undergoing lumbar fusion and collect prospective patient reported outcome measures as specified elsewhere in this document



1. Standardized and rapid recovery track utilized to mobilize patients following surgery:

a) Accelerated physical therapy and mobilization provided if regional pain control is acceptable;

http://www.hca.wa.gov/hta/Documents/findings_decision_bmp.pdf


c) Patients are instructed in home exercise, use of walking aids, and precautions;

d) Care Partners are instructed to assist with home exercise regimen

2. Patients that meet CMS standards for placement in a skilled nursing facility have their post-operative nursing and rehabilitative needs addressed

3. Hospitalists or appropriate medical consultants are available for consultation to assist with complex or unstable medical problems in the post-operative period

B) Standardized hospital discharge process used, aligned with Washington State Hospital Association (WSHA) toolkit

1. Follow up arranged with care team according to WSHA toolkit and Bree Collaborative Potentially Avoidable Hospital Readmissions Report and Recommendations


3. Medications reconciled

4. Patient and family/caregiver provided education with plan of care regarding:

a) Signs or symptoms that warrant follow up with provider;


c) Contact information for the spine surgeon and primary care provider

5. Post-discharge phone call ensured to patient by care team to check progress, with timing of call aligned with Bree Collaborative Potentially Avoidable Hospital Readmissions Report and Recommendations

6. Post-discharge summary sent to primary care provider or after care provider within three business days of discharge

C. Home health services arranged

1. Patient and Care Partner provided with information about medically recommended home exercises

2. Arrange additional home health services as necessary

D. Follow up appointments scheduled

1. Return visits scheduled as appropriate

2. Patient-reported functional outcomes measured with standard instrument

3. If opioid use exceeds six weeks, a formal plan for opioid management is developed


VIII. Total Knee and Total Hip Replacement Surgical Bundle

Read the full report here: http://www.breecollaborative.org/wp-content/uploads/tkrthr_bundle.pdf


ASSESSMENT SCORE


PART I: Bree recommendations are followed for ensuring disability despite conservative therapy


PART III: Bree recommendations are followed for repair of the osteoarthritic joint



I. DISABILITY DUE TO OSTEOARTHRITIS DESPITE CONSERVATIVE THERAPY

A) Disability documented

1. Disability documented according to Knee Osteoarthritis Outcome Score (KOOS) or Hip Osteoarthritis Outcome Score (HOOS)

2. Self-reported productivity loss documented related to usual activity (absenteeism and presenteeism)

B) Osteoarthritis documented

1. Standard x-ray of the affected joint reviewed and interpreted according to Kellgren-Lawrence scale. Total joint replacement therapy generally requires a grade of 3 or 4

http://www.breecollaborative.org/wp-content/uploads/tkrthr_bundle.pdf

C) Conservative therapy for at least three months documented unless symptoms are severe and x-ray findings show advanced osteoarthritis

1. Patient-customized conservative treatments carried out for at least three months, focusing on improving functionality and helping patients adapt to persisting functional limitations

2. One or more of the following physical measures conducted: a) Strengthening exercises; b) Activity modification; c) Assistive devices; d) Bracing if judged appropriate; e) Weight loss, if indicated

3. Trial of one or more of the following medications conducted: a) Acetaminophen; b) Oral non-steroidal anti-inflammatory drugs; c) Topical non-steroidal anti-inflammatory drugs; d) Intra-articular injection of corticosteroids

D) Failure of conservative therapy documented

1. Lack of improvement in pain and/or function documented as indicated by re-measurement of HOOS/KOOS scores

2. X-ray findings supporting need for surgery documented: a) Grade 3 or 4 on Kellgren-Lawrence scale, if not previously documented; b) Avascular necrosis of subchondral bone with or without collapse; c) Angular deformity of limb with threatened stress fracture

3. Informed decision making documented after maximal effort and benefit of conservative treatment

II. FITNESS FOR SURGERY

A) Requirements related to patient safety documented

Patient meets the following minimum requirements prior to surgery:

a) Body Mass Index less than 40;

b) Hemoglobin A1c less than 8% in patients with diabetes;

c) Adequate peripheral circulation to ensure healing;

d) Adequate nutritional status to ensure healing;

e) Sufficient liver function to ensure healing;

f) Control of opioid dependency, if present;

g) Avoidance of smoking for at least four weeks pre-operatively;

h) Absence of an active, life-limiting condition that would likely cause death before recovery from surgery;

i) Absence of severe disability from a condition unrelated to osteoarthritis that would severely limit the benefits of surgery

j) Absence of dementia that would interfere with recovery – performing TKR/THR surgery for a patient with such dementia requires preauthorization, informed consent of a person with Durable Power of Attorney, and a contract with the

patient’s care provider

B) Patient engagement documented

1. Patient participates in Shared Decision-making with WA State-approved Decision Aid

2. Patient designates a personal Care Partner

3. Patient and Care Partner actively participate in the following:

a) Surgical consultation;

b) Pre-operative evaluation;

c) Joint replacement class and/or required surgical and anesthesia educational programs;

d) In-hospital care;

e) Post-operative care teaching;

f) Patient’s home care and exercise program

4. Patient participates in end of life planning, including completion of an Advance Directive and designation of Durable Power of Attorney

C) Optimal preparation for surgery documented

1. Pre-operative history, physical, and screening lab tests based on review of systems:

a) Evaluate for cardiac and pulmonary fitness;

b) Obtain basic lab profile, plasma glucose, prothrombin time, complete blood count, urinalysis with culture, if indicated;

c) Culture nasal passages to identify staphylococcal carrier state;

d) Ensure A1c 8% or less in patients with diabetes;

e) Perform x-rays of knee or hip, if not performed within previous 12 months;

f) Screen for predictors of delirium

2. Relevant consultations obtained

a) Evaluate for good dental hygiene with dental consultation as necessary;

b) Refer to Anesthesia for pre-operative assessment;

c) Consult Physical Therapy to instruct in strengthening of upper and lower extremities;

d) Request additional consults as necessary

3. Patient-reported measures collected:

a) General health questionnaire completed: Patient Reported Outcomes Measurement Information System-10 (PROMIS-10);

b) HOOS/KOOS survey completed

III. REPAIR OF THE OSTEOARTHRITIC JOINT

A) General standards for a surgical team performing TKR/THR surgery are followed:

1. The surgeon performs at least 50 joint replacements a year

2. Members of the surgical team have documented credentials, training and experience; the roster of the surgical team is consistent

3. Elective joint arthroplasty is scheduled to begin before 5:00 pm

4. Facilities in which surgery is performed have policies that align with the American College of Surgeons Statement on Health Care Industry Representatives in the Operating Room



a) Multimodal pain management format used to minimize sedation and encourage early ambulation

b) Opioid use minimized

c) Other anesthesia-related risk factors such as sleep apnea and pulmonary hypertension are assessed and managed


a) Application of chlorhexidine skin prep by patient required at bedtime and morning prior to surgery;

b) Surgical hoods or laminar flow technique used with closed or limited access to operating room;

c) Appropriate peri-operative course of antibiotics administered according to Centers for Medicare and Medicaid Services (CMS) guidelines set forth in the Surgical Care Improvement Project;

d) Use of urinary catheter restrict to less than 48 hours



b) Standardized IV fluid protocols used including those implemented by RNs postoperatively with appropriate supervision and monitoring;

4. Deep venous thrombosis and embolism avoided according to CMS guidelines set forth in the Surgical Care Improvement Project

5. Hyperglycemia avoided: Standardized protocol used to maintain optimal glucose control

C) Selection of the surgical implant

1. Providers select an implant that has a <5% failure rate at ten years

2. To track outcomes, all implants are registered with a national joint registry such as the American Joint Replacement Registry

3. Informed consent includes the experience level of the surgeon with the device



1. A rapid recovery track is utilized to mobilize patients on the day of surgery:

a) Accelerated physical therapy and mobilization provided if regional pain control is acceptable;


c) Patients instructed in home exercise, use of walking aids and precautions;

d) “Care partner” instructed to assist with home exercise regimen

2. Patients that meet Medicare standards for placement in a skilled nursing facility have their post-operative nursing and rehabilitative needs addressed.

3. Access to hospitalists or appropriate medical consultants provided for consultation to assist with complex or unstable medical problems in the post-operative period

B) Standardized hospital discharge process used is aligned with Washington State Hospital Association (WSHA) toolkit

1. Follow up with care team arranged according to WSHA toolkit


3. Medications reconciled

4. Patient and family/caregiver educated with plan of care regarding:

a) Signs or symptoms that warrant follow up with provider;


c) Contact information for orthopedist and primary care provider

5. Post-discharge phone call to patient done by care team to check progress, with timing of call aligned with WSHA toolkit

6. Hospital discharge kit provided upon discharge according to WSHA toolkit

C) Home health services arranged

1. The patient and Care Partner are provided with information about home exercises that should be done three times daily

2. Additional home health services are arranged as necessary

D) Follow up appointments scheduled

1. Return visits scheduled as appropriate

2. Patient-reported functional outcomes are measured with KOOS/HOOS instrument

3. If opioid use exceeds six weeks, a formal plan is developed for opioid management


IX. Prostate Cancer Screening

Read the full report here

http://www.breecollaborative.org/wp-content/uploads/Prostate-Cancer-Recommendations-Final-15-11.pdf


ASSESSMENT SCORE

There is support for communication and education of patients that accurately reflects the most recent medical knowledge on PSA testing for prostate cancer screening

Discussions are encouraged between clinicians and patients about the potential harms, benefits, and conflicting evidence for PSA testing for prostate cancer screening. Only men who express a definite preference for screening should have PSA testing


http://www.breecollaborative.org/wp-content/uploads/Prostate-Cancer-Recommendations-Final-15-11.pdf

X. Oncology Care


http://www.breecollaborative.org/wp-content/uploads/Oncology-Care-Final-Recommendations-2016-03.pdf


ASSESSMENT SCORE

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

PET, CT, and radionuclide bone scans are not used in the staging of early breast cancer that is at low risk of spreading

Palliative care is offered alongside active anti-cancer care, as needed

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

Patients are apprised of the harms, benefits, evidence, and potential impact of chemotherapy, radiation, molecular therapy, immunotherapy, and surgery at all stages in their illness trajectory

Goals of treatment are discussed at beginning of treatment


XI. Addiction and Dependence Treatment


http://www.breecollaborative.org/wp-content/uploads/ADT-Final-Report.pdf

http://www.breecollaborative.org/wp-content/uploads/ADT-Final-Report.pdf

http://www.breecollaborative.org/wp-content/uploads/Oncology-Care-Final-Recommendations-2016-03.pdf


ASSESSMENT SCORE

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

Staff are educated on:

a) The prevalence of alcohol and other drug misuse;

b) Current trends in alcohol and other drug misuse;

c) The impact of alcohol and other drug misuse on health conditions,

d) That substance use disorder is a chronic, relapsing-remitting disease on a continuum, and

e) The importance of screening for alcohol and other drug misuse

Health care providers and other appropriate staff are trained to provide non-judgmental, empathetic, culturally competent, and accepting conversations about and screen for alcohol and other drug misuse

Staff are trained to provide brief intervention and, if possible, brief treatment

Adolescents with addictions are managed collaboratively with child and adolescent addiction specialists, if available

Wherever possible, coordinated, wrap-around care for pregnant women is provided with appropriate primary, addiction, obstetric, and pediatric providers.

Staff are trained how to do a 42 CFR part 2 compliant release of information


XII. Prescribing Opioids for Pain

Read the endorsement here: http://www.breecollaborative.org/wp-content/uploads/2015AMDGOpioidGuideline.pdf and summary here: http://www.agencymeddirectors.wa.gov/Files/FY16-288SummaryAMDGOpioidGuideline_FINAL.pdf


http://www.agencymeddirectors.wa.gov/Files/FY16-288SummaryAMDGOpioidGuideline_FINAL.pdf

http://www.breecollaborative.org/wp-content/uploads/2015AMDGOpioidGuideline.pdf

ASSESSMENT SCORE

All pain phases

Non-opioid therapies are used, such as behavioral intervention, physical activity and non-opioid analgesics when appropriate

Opioids are avoided if the patient has significant respiratory depression, current substance use disorder, history of prior opioid overdose, or a pattern of aberrant behaviors

Function and pain are assessed and documented using a validated tool at each visit where opioids are prescribed

Opioids are not prescribed with benzodiazepines, carisoprodol, or sedative-hypnotics

Acute phase (0–6 weeks)

The state’s Prescription Monitoring Program (PMP) is checked before prescribing

Opioids are not prescribed for non-specific back pain, headaches, or fibromyalgia

The lowest necessary dose is prescribed for the shortest duration

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

Patient is discharged with acetaminophen, NSAIDs, or very limited supply (2–3 days) of short-acting opioids for some minor surgeries

Patients on chronic opioids have doses tapered to preoperative levels or lower within 6 weeks following major surgery

Subacute phase (6–12 weeks)

Patients are not continued on opioids without clinically meaningful improvement in function and pain

Patients are screened for comorbid mental health conditions and risk for opioid misuse using validated tools

If opioids are prescribed beyond 6 weeks, PMP is rechecked and a baseline urine drug test is administered

Chronic phase (>12 weeks)

Opioids are continued to be prescribed only if there is sustained clinically meaningful improvement in function and pain, and no serious adverse events, risk factors, or contraindications

PMP checked and urine drug test are rechecked at frequency determined by the patient’s risk category

Opioids are prescribed in 7-day multiples to avoid ending supply on a weekend

120 mg/day morphine equivalent dose is not exceeded without a pain management consultation


XIII. End of Life Planning


http://www.breecollaborative.org/wp-content/uploads/EOL-Care-Final-Report.pdf


ASSESSMENT SCORE

Health care providers and staff are educated on:

a) How to have empathetic, realistic, and patient- and family-centered (e.g., using lower literacy materials if appropriate) advance care planning conversations;

b) How to be reimbursed for these conversations;

c) The difference between an advance directive and POLST, and patients for whom each would be acceptable;

d) How to refer patients to community-based advance care planning resources if appropriate;

e) Explaining the terms on an advance directive and POLST to family and friends at the end of a patient’s life;

f) Supporting the patient, family, and friends during a time of crisis.

Organization has worked with your community’s organizations (e.g., churches, non-profits focused on end-of-life care) to promote community-wide discussions about how to have conversations regarding personal goals of care and the type of care desired at the end of life with family members, friends, health care providers; the importance of having an advance directive that includes a living will (also known as a health care directive), a durable power of attorney for health care, and a written personal statement about health care goals and values; and the difference between POLST and an advance directive

http://www.breecollaborative.org/wp-content/uploads/EOL-Care-Final-Report.pdf

Organization’s protocol has been reviewed regarding asking about and honoring advance directives to decrease barriers to patients’ wishes being honored at the end of life

An advance care planning tool is in used across your system. Examples include Honoring Choices Pacific Northwest or the Institute for Health Care Improvement’s Conversation Ready.

Advance directives and/or POLST are entered into the patient’s medical record once completed.

Advance directives and/or POLST that originate in the hospital are communicated back to the patient’s primary care provider.

Awareness of the value of hospice is promoted, with encouragement of appropriate hospice referrals.

Hospice referrals that originate in the hospital are communicated back to the patient’s primary care provider.

A quality improvement program is implemented to encourage greater adherence to patients’ requests as outlined in advance directives and POLST if accurate and applicable to the current situation

Family and friend satisfaction with end-of-life care are measured by widespread use of an after-death survey tool similar to that used by hospice agencies

Patients are supported as they navigate care between different health care facilities and systems including facilitation of information sharing and patient and family outreach during times of crisis


XIV. Potentially Avoidable Hospital Readmissions


http://www.breecollaborative.org/wp-content/uploads/Readmissions-Report-FINAL-14-0730.pdf


ASSESSMENT SCORE

http://www.breecollaborative.org/wp-content/uploads/Readmissions-Report-FINAL-14-0730.pdf

There is participation in a hospital readmission collaborative recognized by WSHA or Qualis Health

Washington State Hospital Association’s Care Transitions Toolkit has been adopted, as clinically appropriate


XV. Factors affecting adoption (Barriers/Enablers)

Considering your responses in this survey, indicate those factors that were barriers to, or enabled adoption. Rank order 1-5 the top 5 factors in the BARRIERS column those barriers that apply, also rank 1-5 in the top 5 Enablers column those that contributed to adoption. Add factors if appropriate.

FactorTop 5

Barriers to Adoption(rank 1-5)

Top 5 Enablers to Adoption(rank 1-5)

Internal awareness/support of Bree RecommendationsSufficient market share/volumeBusiness case- evidence of economic rewardContract partners interest in value-based purchasingExisting forum to discuss value-based purchasingConsensus on what constitutes quality of careAvailability and credibility of dataIndividual provider-level performance and feedbackBurden/ease of collecting or obtaining dataConsistency in findings across multiple measuresExisting organizational improvement program for minimizing errors & wasteConsumer awareness of quality health plans and providersRegulatory constraints, i.e. HIPPA, etc.Other:
