The Spotlight on Improvement series highlights real stories of health care quality improvement. These case studies can be used to improve health care programs and spark new collaborations.

How Low Can You Go?

Last week, I had the opportunity to attend the Seattle Business magazine awards gala to recognize Health Care Leaders in the state. It was wonderful to see Alliance members and allies, and to take a moment to acknowledge the important work we do.

This year, the Alliance recognized outstanding performers from our third edition of First, Do No Harm, using the Milliman MedInsight Health Waste Calculator to calculate how much unnecessary or likely unnecessary care was delivered to Washington residents of the 47 tests, treatments, and procedures commonly regarded as overused by Choosing Wisely and the US Preventive Services Task Force.

The evening was a wonderful opportunity to honor two shining examples of how we in Washington state are reducing unnecessary care and the emotional, physical, and financial harm that often cascades from it. Because of the patients they serve, that is top of mind for Dr. Mia Shim, the Medical Officer of the Community Health Services Division for Public Health—Seattle & King County, recognized for delivering the lowest number of low-value treatments in the state for the Medicaid-insured, at 46% fewer than average services at a 54% lower than average cost per month.

“Our patients may not have the basic resources or education to navigate our complex health systems, so they really need us to be thoughtful and adaptive about what brings them value. For their sake, we need to avoid unnecessary tests and treatments, which can be both harmful and costly.” Dr. Shim credits their performance in First, Do No Harm to Public Health—Seattle & King County’s long history of providing patient-centered evidence-based care, explaining that they were “very early in recognizing the hazard of overprescribing controlled substances, including opioids, and developing clinical teams to oversee and standardize controlled substance prescribing practice more than ten years ago.”

Dr. Shim says they have a bottom-up approach to providing value, “many of the best ideas come from people who see patients every day. So, it’s important that they have dedicated time for quality improvement work that is tied to outcome. To deliver value, we must both improve the quality of services and reduce costs, and the frontline staff are leaders in achieving value.”

I also took a moment to acknowledge PeaceHealth Medical Group for its outstanding performance for the commercially-insured population, delivering 37% lower than the average number of low-value treatment and 35% less than the average spent monthly.

It was a pleasure to recognize them and to see these Alliance members and organizations honored for their valuable contributions:

    • Lisa Brandenburg, Chief Health System Officer at UW Medicine (Outstanding Medical Center Executive-Puget Sound);
    • Dr. Nancy Davidson, Executive Director and President, Seattle Cancer Care Alliance (Outstanding Medical Group Executive);
    • Dr. Craig Hampton, Medical Director of Cardiac Surgery at CHI Franciscan (Outstanding Medical Director);
    • Dr. Rick Ludwig, Interim CEO of Pacific Medical Centers and Medical Director of U.S. Family Health Plan at Pacific Medical Centers (Lifetime Achievement Award);
    • Dr. Glenn Lux, President/CEO, Allegro Pediatrics (Outstanding Medical Group Executive);
    • Dr. Aileen Mickey, Chief Medical Officer at EvergreenHealth Medical Group (Outstanding Chief Medical Officer);
    • Dr. Jay Shendure, UW School of Medicine & Brotman Baty Insititute for Precision Medicine (Achievement in Medical Research); and
    • CHI Franciscan Mission Control Center and Confluence Health | Central Washington Hospital (Innovation in Health Care Delivery).

A heart-felt congratulations to all!

All the best,

Nancy A. Giunto

Health Management Associates joins the Alliance

This month, we’re excited to welcome Health Management Associates as the newest member of the Alliance.

About Health Management Associates

Health Management Associates (HMA) is a leading independent national research and consulting firm in the healthcare industry. Founded in 1985, today they are more than 200 consultants strong and still growing. Their team comes from all sides of the publicly-funded healthcare arena, bringing an intimate understanding of the unique challenges and constraints their clients face. Working across multiple disciplines and in all 50 states, the District of Columbia, and Puerto Rico, HMA puts that expertise to work for every client.

Learn more about Health Management Associates here.

Reflections and Resolutions from the Corner Office

I’m proud to say that 2019 brought the Alliance several firsts-in-the-nation and in our state. We:

  • reported on the wide variation of actual prices for inpatient treatment (including facility and physician charges) not only across Washington, but within individual hospitals;
  • revealed the underlying reasons why there was a decline in inpatient spending with our statewide trend analysis results; and
  • ranked medical groups on waste, using the Milliman MedInsight Health Waste Calculator™ for both Medicaid and the commercially-insured and found an encouraging statewide downward trend for the tests, treatments, and procedures we measured.

We received quite a bit of attention for our groundbreaking work this year–you may have seen us in Health Affairs, Modern Healthcare, or Consumer Reports. At the annual Birnbaum lecture, Dr. Eric Larson said the Alliance is giving “great hope for positive change” (you’ll find us about 27 minutes in). Lauded as being among “Washington’s most accomplished health care innovators” and for “literally transforming health care as we know it,” the Alliance and Milliman MedInsight were honored by Seattle Business magazine for our work identifying waste in the 47 commonly overused tests, treatments and procedures.

Looking back at our accomplishments, it would not be complete without acknowledging our incredible Board of Directors, diligent committees, devoted members, and staunch allies. Whether wholeheartedly supporting our work or challenging us to think bigger and expand our horizons, you are the most important part of what we do. That’s why we are very much looking ahead to working with you to make 2020 our best year yet:

  • breaking down inpatient spending trends not only by individual hospital, but also by diagnosis;
  • releasing publicly for the first time The Hospital Value Report showing a comparison by hospital about all aspects of value – quality, patient experience, and cost;
  • launching the 9th eValue8 process to compare health insurance plans across a wide variety of metrics;
  • issuing our latest Community Checkup report, comparing our state health population to national benchmarks and ranking medical groups;
  • assuming the Lead Organization role for the Washington All Payer Claims Database through a strong public-private partnership with the Washington State Health Care Authority;
  • finalizing and implementing a new methodology to score and rank provider performance on quality in a summarized fashion;
  • advancing our First, Do No Harm report with interested self-funded insurers; and
  • implementing a Board impact project in which every organization represented on that body works together to reduce inappropriate use of opioids for low back pain and for dental care.

We continue to share our evidence-based expertise both within our state and across the country. This year, our message reached from Capitol Hill to the nation’s Capitol, from Kirkland to Kansas City, from Blaine to Baltimore, and from Redmond to Rhode Island (just to name a few). It was particularly rewarding when the Alliance was acknowledged not by one, but by two speakers from the podium at NRHI’s Affordability Summit in Minneapolis; by Milbank President Chris Koller and bestselling author of The Price We Pay: What Broke American Health Care—And How to Fix It, Dr. Marty Makary.

The next year will also bring some changes to our team. Deputy Director Susie Dade announced in December that after 14 years, it’s time to depart from the Alliance in early April and move on to her next chapter. Susie joined the Alliance when it was still a very young start-up and helped to shape and launch so much of what and who we are today. Her contributions to the Alliance are vast and she certainly will be missed. I’m sure you will agree that she will always have a home here. Please take a moment to wish her well and thank her for strengthening the work of the Alliance in so many ways. If you know someone who would like to join us as our Director of Performance Improvement and Innovation, please pass along our job posting. And if you haven’t already, be sure to welcome our new Director of Membership and Business Engagement, Theresa Lampkin Tamura, who joined us in September. She’d be happy to hear your ideas for potential members, All-Alliance meetings, new member benefits, or other initiatives the Alliance should consider. You can reach her at or 206-454-2957.

As we embark on this, our 15th year, we will continue to do this important work, to analyze health care data and to release our findings to help improve the health care system in Washington state. But more importantly, we look forward to continuing our work alongside all of you to propel action.

The work we do together to transform health care is challenging.  It takes courage to ask the tough questions and then to support public reporting on the results. As we embark on a new decade of working together to improve the quality and affordability of health care for Washingtonians, I am reminded of this quote, “Be thankful for the struggles you go through. They make you stronger, wiser and humble. Don’t let them break you. Let them make you.”

Wishing you all the very best in 2020,

Nancy Giunto

Exact Sciences joins the Alliance

This month, we’re excited to welcome Exact Sciences as the newest member of the Alliance.

About Exact Sciences

Exact Sciences is molecular diagnostics company focused on the early detection and prevention of colorectal cancer with its non-invasive screening product, Cologuard. Exact Sciences estimates that 3 million people have used Cologuard since it was launched, resulting in the detection of 14,000 early-stage cancers and 98,000 pre-cancerous polyps. Exact Sciences is now expanding its detection screening to address liver cancer, for which there are an estimated 3 million high-risk Americans.

Learn more about Exact Sciences here.

The Alliance Takes on the Wall Street Journal

You may have seen the recent Wall Street Journal article, “Posting Health Prices Online Isn’t Cure-All.” In it, the reporter takes a close look at New Hampshire’s twelve years of experience of posting prices online and concludes that there have been few benefits: prices have not significantly decreased, overall spending has been reduced only marginally, and few consumers use the site. Even though “New Hampshire has one of the most comprehensive and oldest hospital price-transparency laws in the U.S.,” the article suggests it’s a failed experiment.

While I agree that price transparency alone will not compel the change we need, I believe the article fell short on the most important ingredient of change. It’s not just how price transparency can change health care, but how transparency coupled with engaged multi-stakeholder support can propel action. As Leonardo da Vinci said, “Being willing is not enough. We must do.” When it comes to the Alliance, doing means bringing all of the different stakeholders together to inspire thoughtful conversations that lead to measurable improvements.

  • To help more than 15,000 employees access high quality health care, King County incorporated Alliance quality data in designing benefit plans and creating employee engagement programs, making it possible for them to make better health care decisions.
  • To better address the health care needs of its 18,000 home health caregivers, SEIU 775 learned from other Alliance members about ways to expand their behavioral health offerings, including launching a new mobile coaching app, video chats, screenings and online mindfulness classes, resulting in higher quality care.
  • The Everett Clinic used the Hospital Value report to identify areas that needed improvement and take action to make that possible.

These organizational choices have resulted in quality improvements for hundreds of thousands of people whose care is not only beating the Community Checkup’s statewide averages for care, but the HEDIS 10% national benchmarks.

We know that providing pricing and quality data is critical, but the key to change is the ability to bring all of the different and, sometimes, competing interests together towards the same goal. That is why we worked with the statewide Choosing Wisely Task Force to create the “Drop the Pre-Op” campaign to reduce the number of unnecessary preoperative lab tests on healthy people before low-risk procedures. In our last waste report, unnecessary pre-ops were responsible for an estimated $85.2 million in wasteful services impacting 122,257 individuals. Tremendous work remains ahead to eliminate these unnecessary tests in hospitals across our state and we stand ready to help in these efforts.

So yes, we agree with the Wall Street Journal that price transparency alone isn’t the answer. But, if we bring all of the stakeholders to the table and combine price transparency with quality measurement and waste reduction, and then put that information to work in purchasing, benefit design, changing practice patterns, and changing consumer behavior, that’s when we will drive changes in our health care system.

How do I know this? Because we already are.

I look forward to making more of that possible with you.

All the best,

Nancy Giunto

The True Value of Exercise

It’s officially summer and I am appreciating the opportunity to spend more time in the garden with these long warm days, but it got me thinking about some recent studies on exercise. Did you know that according to a recent study by the CDC, less than 25% of adults in the US get enough physical activity? Here in Washington state, the rate is a little better–28.9% said that they fulfilled the federal recommendation for weight-strengthening exercise at least twice a week and 75 minutes of high-intensity aerobic activity like running or 150 minutes of moderately intense exercise such as brisk walking each week from 2010-2015. But may I ask, what about all those other folks? In some states, like Indiana, Kentucky, and South Carolina, the percentage of nonworking women who met the federal exercise guidelines was in the single digits–less than 10%.

Most of us know about the 10,000 steps a day goal, but a Journal of American Medicine Internal Medicine study shows that you don’t have to hit that magic number to make significant differences to your health. In fact, there are benefits to walking much less. In fact, for older women, even 4,400 steps a day helped lower mortality rates compared to those who walked 2,700 steps a day. Sounds so easy, doesn’t it? But it’s not. Across the board, men exercise more than women, and nonworking adults exercise less than working adults. One would think with more time, you’d have the ability to exercise more, but it’s simply not the case.

A Johns Hopkins study published in the Journal of American Medicine illustrates my point. Researchers asked, “What are the trends and health care expenditures associated with not meeting the recommended physical activity for women with cardiovascular disease?” We’re talking about the same requirement, 30 minutes or more of moderate to vigorous intensity exercise 5 or more days a week. Of the more than 18,000 women studied, more than half of them reported not meeting that activity level. In 2006, 58% didn’t meet it and by 2015, that percentage rose to 62%.

And when you take a closer look at the data (which I am wont to do) the results are even worse for specific groups. For women aged 40-64, 53% of them had insufficient physical activity in 2006 and that increased to 61% in 2015. For African-American women, the rate increased from 56% to 67%. For the college-educated, it rose from 45% to 58%. And for women with high incomes, it increased from 49% to 60%. The Johns Hopkins study estimates that $117 billion in annual health care costs are attributed to not meeting physical activity guidelines. We could all improve not only our health but our health care costs by ramping up on exercise.

As if that weren’t enough, the World Health Organization recently issued its first guidelines on preventing dementia and it included the same physical activity recommendation. In addition to not smoking and drinking, you should keep exercising to keep your brain healthy. And a pilot study in Canada explored a home-based exercise program to find out whether it would help older surgery patients recover better. In Canada, more than half of all major surgeries involve patients over 65 and about 40% of them are frail, which increases the risk of complications and disability. There are more than 100,000 older patients who have surgery every year in Canada and while the results of the initial 100 participants are being reviewed, researchers hope to see positive results from an expanded study improving muscle strength, cardiovascular fitness, and flexibility for 750 participants across Canada this fall.

On the opposite side of the age spectrum, exercise can even play a part in an infant’s metabolism. Researchers at The Ohio State University and Joslin Diabetes Center found evidence that a father’s level of exercise can play a role in a child’s body weight and glucose tolerance. Mice in a study were divided between offspring of dads who exercised and had a high fat diet and those who were sedentary. The results show better metabolic health in the adult offspring of those mouse dads who were more active.

Exercise and a healthy diet are two key components of preventing type 2 diabetes. A recent Diabetes Epidemic and Action report indicated that about 623,000 adults in Washington state have diabetes and a quarter of them are not aware of their diagnosis. From our Community Checkup we know that as a state have a way to go to reach the national 90th percentile established by the NCQA HEDIS measures for all diabetes-related care measures, not just eye exams. But we also know that some providers exceed that quality standard already and my hope is they will pave the way for others.

In the meantime, we all know it’s better to be active than sedentary, what we don’t always think about is how it plays a part in our quality of life, health care costs, as we age, and, even in our children’s health and well-being.

Clearly it’s never too late (or too early)! Take some time to head to the gym, take a yoga class or go for a long walk.

All the best,

Nancy Giunto

One Key Question: A simple screen for pregnancy desires in primary care settings

The problem

Pregnancy causes changes that cascade through a woman’s life and that of her family, and can have large health impacts—especially for those already struggling with chronic disease, poor mental health, or stressful circumstances. We now know that pregnancy timing and circumstances affect not only a prospective mother’s health but also the wellbeing of her children. A woman’s pre-pregnancy status can shape her child’s developmental trajectory and risk of chronic conditions decades later. But in Washington State, 37 percent of pregnancies are unintended, a measure that is included in the Washington State Common Measure Set for Health Care Quality and Cost.  Such a rate does not allow many women and doctors to build preconception resources that support healthy pregnancy, healthy babies, and healthy parenthood.

State-of-the-art contraceptive technologies—long acting “get-it-and-forget-it” IUDs and progestin implants—are 20 times as effective as the Pill. They dramatically reduce mistimed or unwanted pregnancy, as shown by the Colorado Family Planning Initiative, which cut teen births and abortions nearly in half and reduced preterm births.  Professional bodies now recommend implants and IUDs as top-tier protection for most women, including teens and those who are HIV-positive. But busy primary care providers often don’t know whether a patient wants to get pregnant or avoid pregnancy, and so may miss opportunities to help patients.

With unintended pregnancy so common and the consequences so significant, the American College of Obstetricians and Gynecologists now recommends that health care providers touch on reproductive life planning at every visit with reproductive-age women. Clinicians want to help their patients manage health conditions and stack the odds in favor of flourishing children, but are swamped with ever more tasks and topics to cover and ever smaller chunks of time in which to address them all.

The solution

The Oregon Foundation for Reproductive Health, a Portland-based nonprofit, has developed a simple, quick method called One Key Question® (OKQ) to screen routinely for pregnancy intentions in reproductive age patients. The one key question is this: “Would you like to become pregnant in the next year?” The clinician documents one of four patient responses:  Yes, I’m OK either way, I’m not sure, or No, followed by evidenced-based care that supports their answer.

Patients who respond yes receive preconception counseling, which identifies health behaviors change or care that could support a healthy pregnancy. Patients who feel uncertain or ambivalent receive information about preconception care as well as contraception.  A response of no leads to a conversation about family planning options, giving an opportunity to check in on current satisfaction and explore less familiar methods that might better fit. Inexpensive posters and tear sheets from the National Campaign to Prevent Teen and Unintended Pregnancy and a color coded medical eligibility chart from the CDC make it easy to step through family planning options


One Key Question is rapidly becoming a national model. One example is the state of Delaware, where Governor Jack Markell partnered with Upstream USA  to retool contraceptive care statewide, so that women can receive the method of their choice same day, free of charge—including IUDs and implants.  The upgrade, called Delaware CAN, included OKQ screening to identify the preventive reproductive health needs of patients.

In Oregon, OKQ is being deployed in a variety of settings, from home-visiting and WIC to primary care.  A pilot project at One Community Health compared two major health centers, one in which OKQ was implemented and one without. At one month, 64% of electronic medical records for the intervention site documented appropriate screening for pregnancy desires, compared to 12% at the non-intervention site, suggesting that staff were able to incorporate the change into their normal workflow of patient care.


Even for clinicians who would like to improve reproductive outcomes for their patients, adopting a screening protocol such as One Key Question can be challenging.

  • Sexuality and reproduction can be sensitive topics for providers as well as patients. In particular, those women who are young, poor, ethnic minorities, or in ill health can feel shamed or pressured unless conversations are carefully client-centered. That said, women say that they want their providers to ask.
  • At a practical level, incorporating the OKQ algorithm into varying electronic health records continues to be a major barrier for health centers that want to use OKQ in a systematic and routine way.
  • Asking about pregnancy intentions can uncover desire for better birth control or for preconception care, requiring staff training or other increases in capacity. (The “Beyond the Pill” program at UCSF offers onsite trainings to clinics wanting to upgrade contraceptive services, with grant funding for those that qualify.)

Keys to success

To ensure program excellence and compatibility of evaluation across settings, the non-profit Oregon Foundation for Reproductive Health trademarked One Key Question and asks for a signed memorandum of understanding prior to implementation. In settings that have adopted OKQ, the following components have been keys to success:

  • Conduct comprehensive training with health center team before roll-out
  • Integrate screening into current workflow practice
  • Renew protocols or referrals for preconception and contraception care
  • Develop a plan to evaluate impact of screening on other services provided

To learn more about One Key Question or to sign up for a monthly newsletter, please contact

CHI Franciscan Health System: Making strides toward more appropriate use of the ER

February 2015: CHI Franciscan Health System, Pierce, Kitsap and south King counties, Wash.

CHI Franciscan is making great strides to reduce avoidable emergency room use. By focusing on providing their patients alternatives to more costly emergency room visits, they have become top performers in the region for their low rates of avoidable emergency room use.

View February 2015 Spotlight on Improvement (PDF 488 KB)

Swedish Medical Center: Rethinking the practice of ordering daily labs to reduce waste and improve care

November 2014: Swedish Medical Center, Seattle, Wash.

Read how Swedish Medical Center is making a big impact through a simple, innovative solution—changing the practice of ordering “daily labs,” or a lab automatically ordered for every day a patient is in the hospital. Following Choosing Wisely recommendations, Swedish Medical Center encourages physicians to only order tests that are clinically relevant. The results? This simple process change is resulting in 14,000 fewer unnecessary lab tests annually.

View November 2014 Spotlight on Improvement (PDF 498 KB)