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Highlights of our Journey with ACS-NSQIP
Surrey Memorial Hospital
Surgeon Champion CallAugust 2010
QI in NSQIPDo we have to?How ?Who is responsible?What is acceptable?What`s the worst that could happen ?
Data Quality Control
Data Quality Control
SC and SCR meetingsSCR and Surgical Program Director meetings
Identify data errorsMultiple postop occurrencesInpatient/OutpatientsSubspecialtyCPT CodeDOB Wound Class
0
0.5
1
1.5
2
2.5
3
3.5
4
108.
0011
4.00
141.
0089
.00
66.0
011
3.00
88.0
019
.00
111.
008.
0080
.00
135.
0012
8.00
127.
0045
.00
15.0
024
.00
122.
0075
.00
72.0
026
.00
100.
0032
.00
58.0
031
.00
52.0
014
7.00
124.
009.
0064
.00
68.0
012
.00
43.0
038
.00
16.0
014
8.00
40.0
050
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85.0
044
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51.0
041
.00
129.
0083
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10.0
054
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143.
0086
.00
48.0
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.00
107.
0049
.00
102.
0029
.00
20.0
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4.00
60.0
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132.
0014
5.00
97.0
081
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91.0
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98.0
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116.
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4.00
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3.00
55.0
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134.
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2.00
103.
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36.0
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6.00
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69.0
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138.
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0.00
105.
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.00
92.0
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9.00
96.0
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77.0
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.00
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90.0
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6.00
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11.0
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0.00
110.
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9.00
115.
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33.0
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1.00
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74.0
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.00
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.00
Overall Renal ComplicationsIncludes General and Vascular Surgery Cases
Outlier status:Needs improvement
Good outcomes
Poor outcomes
ACS-NSQIP Hospital ID Number
Our Hospita
Data Quality ControlCase Detail Report
Data Quality Control
Data Quality Control
Date of Birth ErrorsMM/DD/YYYY vs DD/MM/YYYY
Discharge Information Multiple admissionsMultiple files on EMR for a single admission
Wound Classification Errors15% error per cycle
Data Quality Control
Wound Classification Guidelines
Data Quality ControlMissing Data
Variables Then Now FutureASA 33% 2% Electronic
andmandatory fieldsHeight 37% 24%
Weight 9% 6%OR Reports Available 2-3
months after OR
3-4 weeksSynopticReporting
Smoking History(ppy)
95% 30% Enhanced preop assessment
Labs(Albumin)
79% 53% Links with external lab facilities
30-Day FF-up 92.1% 92.5% Translation Services
ChallengesCPT Codes
*Discuss OR reports with Surgeon Champion*CPT Code mapping on Validation Worksheet
ICD Codes*Surgeon’s offices/MOA
Missing data*Revised nurses notes, assessment forms, anaesthesia record
30-day Follow-up*Telephone script for NSQIP clerks
Data Quality Control
Database Design
Excel spreadsheet with trends and graphs for each projectQuarterly updatesFormulas embedded in excelPivot tablesAccess Database
Data Reporting and SharingInternal
Surgical Committee MeetingsOR Committee MeetingsCouncil of ChiefsChairs of DivisionNewslettersIntranetUpdate – Teams
ExternalFHABCPSQCProvincial and NationalOther NSQIP participating sites
Data Reporting and Sharing
Education
Learning SessionsSurgical Safety Collaborative MeetingsIn-service for frontline nursesDirectors, executives and physiciansNew surgeonsPosters
Input/Output
2007 Semiannual Report
OE trend over time
Action Time
Postoperative Pneumonia
OE
Raw Data – trend over timeIncidence of Pneumonia from
Jan 2007- Mar 2010
0%
1%
2%
3%
4%
5%
6%
Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-Dec 2009 Jan-Mar 2010Rat
e/10
0 Su
rgic
al P
roce
dure
s
SMH
NSQIP
Postoperative PneumoniaMore Data
Emergency vs electivePneumonia Occurrence Emergent vs Elective
0%
2%
4%
6%
8%
10%
Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009
Date
Rat
e
SMH EmergentNSQIP EmergentSMH ElectiveNSQIP Elective
Pneumonia Emergent ElectiveLOS 2008 39 days 25 days
2009 59 days 14 daysMortality 2008 31% 20%
2009 23% 20%RTO 2008 23% 10%
2009 15% 0%
p-value <.0001
Emergent surgeries postop ventillation = 20/40 (50%)postop ventillation + positive culture = 19/40 (48%)Bugs were identifiedCandida Albicans excluded
Postoperative PneumoniaMore Data
Pneumonia Occurrence Emergent vs Elective
0%
2%
4%
6%
8%
10%
Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009
SMH ElectiveNSQIP ElectiveSMH EmergentNSQIP Emergent
Postoperative Pneumonia PreventionSurrey Memorial Hospital
Team Goal:
Future Opportunities• Bowel Resection Carepaths• Changes in Preprinted Orders Reflecting
Initiatives• Preadmission Education Pamphlets Revision
Focusing on Self-Management• Spread and Integration of Bundles in Other
SMH Units and FHA Sites
To decrease the incidence of pneumonia in postop bowel surgerypatients by 50% using NSQIP byOctober 2009.
*NSQIP data results July-Aug 2008: 3.4% Occurrence Rate
Improvement StrategiesPneumonia Occurrence Trend Over Time
General and Vascular Surgeries
0%1%2%3%4%5%6%
07/06-12/06 01/07-06/07 07/07-12/07 01/08-06/08 07/08-11/08
Dates
%
SMH
NSQIP
Spot Checks: Pre -Implementation
October 2008: 50% HOB elevatedFebruary 2009: 71% HOB elevated
Preadmission•Pre-op Education Pamphletwith Pneumonia Prevention
Tips•Encouraging Partnership in Care•Changes in Standard Orders for Preoperative Oral Decontamination
• Mobilization- Dangle post op day 0 if tolerated or HOB elevated - Increase activity as tolerated: Up to chair, walk X 1,2,3 etc.
• Meticulous Hand Hygiene- Prevents transmission of micro-organisms between patients- Infection control involvement on team
• Elevate Head of the Bed 30-40 Degrees- HOB elevation during transport, post op bed or stretcher - Rationale: Improves ventilation- Prevents aspiration of stomach & nasopharyngeal secretions
Deep Breathing and Coughing Exercises- Rationale: Improves ventilation and prevents atelectasis - Assists with movement & expectoration of secretions
• Chlorhexidine Gargle - Pre & post op oral decontamination- Evidence indicates may decrease pneumonia rates post
surgery
Education & Support- Patient and Family Education – Posters in rooms“Prevent Pneumonia” coaching & education pre-& post
surgery for deep breathing & coughing - assisting with mobilization- encouraging self-care in recovery period post surgery- Staff Education – Huddles, emails, staff meetings, clinical
update, new staff orientation
TEAM MEMBERS
Linda Coleman, PT Margaret Dyka-Gluzak, RNLinda Nelson, Educator Anne Edmond RNIrene Harder, RN Brenda Smith, RNMelissa Idle, Physio Raj Pandey, PTAngela Wilson RN Christine Donald, RNAngela Tecson, SCNR Sharon Parent, QIDonna Rolph, Manager
3 South Surgical Front Line Staff
Observed Rate: 2.73%Expected Rate: 1.68%O/E Ratio: 1.62Status: As Exp ected
Risk-Adjusted Pneumonia with Comparisonto Other NSQIP Sites
COMPLETE In Patient’s Room:
HOB elevated 30-40 degrees :Yes No N/A
Patient mobilized day 0:Yes No N/A
Patient dangled for 5 minutes X 1 Yes No N/A Or: HOB up 40 degrees for 5 minutesYes No N/A
Chart#__________Date____________
Spot CheckPneumonia Prevention
Action Team
PDSA Cycles – Best Practices Audits
Pneumonia Prevention Audit
0%
20%
40%
60%
80%
100%
Jun-09 Jul-09 Aug-09
Date of Audit
Rate
HOB ElevatedDBC TeachingDB&C ExercisesMobility Documentation
Mobility Postop Day #0Colorectals
0%
20%
40%
60%
80%
100%
Jun-09 Jul-09 Aug-09 Sep-09
Date of Audit
Rate
HOBDangleWalk
Postoperative UTI
CAUTI Prevention Action TeamSurrey Memorial Hospital
Team Goal:
1. Clinical decision making for Catheter reinsertion (i.e. bladder scan volume - what is acceptable? When does a catheter need to be inserted?) Align with HPA.
1. Continue with Silver Catheter trial and determine sustainability of long term use
1. Spread of CAUTI Prevention action items throughout the site. Initial spread to General Surgical Unit and the surgical program.
UTI Trend Over TimeGeneral and Vascular Surgeries
Team Members:
Jyotika PrasadNen GracesSharon Parent Jane Mann
Improvement Strategies
UTI Trend Over Time
0
1
2
3
4
01/06-06/06 07/06-12/06 01/07-06/07 07/07-12/07 01/08-06/08 07/08-11/08
Dates
%
SMH
NSQIP
1. Silver Catheters:Insertion documented in chart, Kardex and tracking tool. Follow up audit to be done.
Picture
Decrease Catheter Associated Urinary Tract Infection rates 50% in
the fractured hip population by June 2009
As determined by frontline staff
Process Change
1.Trial of silver impregnated catheterIn OR: insertion of silver catheters in bowel proceduresOn Unit: pre-operative insertion of silver catheters in the fractured hip population
Practice Changes
1. Insertion2 person insertionPre-wash perineal areaCHG 2% for aseptic urinary meatus cleaningStatlock securement to unaffected leg
2. MaintenanceNo droopy loops (dependant loops)Drainage bag between bladder and floorNew drainage container q 24hrsRinse drainage container after each drain
3. Removal“2 Days too Long” : Removing a urinary catheter at max post op day 2 at 0600 unless contraindicatedIf catheter remains in place: documenting reason for catheter and plan of careEncourage activities to promote voiding: Mobility, Hydration, Bowel care, Relaxation
Felicia LaingLoretta CastelinoNicole Quilty Cindy Yazlovsky
Linda JenningsRacheal BertramElizabeth AllanAngela Tecson
3S Surgical Orthopaedic Frontline Staff!!
8 x 30 min education sessions (UTI Jeopardy)
4 x 10 min unit based education (create awareness)
Creation of prompts to stimulate awareness
Daily reminders with morning rounds
Kardex Inserts Weekly spot checks led by
frontline staff - continuing awareness for practice changes
UTI Section to Initiative wall with current data of CAUTI infection rates on Unit
CAUTI huddles – in presence of UTI infections
2. Practice Changes: weekly spot checks led by frontline staff.
3. CAUTI Rates:5 patients with catheters (selected from weekly spot check) to be audited on weekly basis
Future Opportunities
Initiation: reach 80% of staff
Sustainability
Obtaining Results
Risk-Adjusted Overall Urinary Tract Infections with Comparison to Other NSQIP Sites
Observed Rate: 2%Expected Rate: 1.34%O/E Ratio: 1.49Status: As Exp ected
U & I can eliminate UTI’s
Actions;
2 person insertion & use smallest possible frenchPrewash perineal area & use chlorehexdine 2%
swabsSecure safely (to unaffected side if limb trauma) No droopy Loops (keep between bladder and bag)Keep bag below the bladder and off the floorLabel drainage container with name and dateRinse after every drain and discard q24hrs
(0600)
Always ask, why is this catheter in? Don’t forget.. .“2 Days Too Long”
For everyday the catheter is in place, please assess, document;
Reason why catheter is in placeHas any follow up/ trial been done re: removal of
catheterWhat is the plan for removalIs the patient exhibiting any signs and symptoms
of UTI?If UTI suspected send C+S, and notify MD.
After catheter removal,mobilize,hydrate patient & provide bowel care. If patient is unable to void follow these steps;consider the type of surgery, pt medical status and orders.…
I/O catheter for volume >400cc, x 2 if still unable to void then,
Foley Catheter overnight and remove in AMIf problem persists, consider urology consult
PDSA Cycle
UTI TREND OVER TIME
0
20
40
Apr-09 May-09 Jun-09
n
Ag Cath w/ UTI 0 0 0
Ag Cath 7 3 2
Reg Cath 18 13 6
Reg Cath w/ UTI 7 2 0
Apr-09 May-09 Jun-09
Orthopedic Ward – Silver Catheter Audit
Baseline Sept 2009 Nov 2009
Statlock on 100% 100%
Plan for removal 50% 50%
Droopy loops 100% 100%
Bag above the bladder 0% 0%
Bag on the floor 0% 0%
Drainage container dated 0% 0%
Catheter LOS (ave) 5 days 3.5 days
GS Ward – Catheter care audit
Surgical Site InfectionFrom bowels to breasts
SSI Rates According to Type of Breast Surgery
3
1514
10
14
20 0
20
31
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Num
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of C
ases
Total Number of Cases Cases with SSI
Surgical Site Infection InitiativesSafer Healthcare Now
Preop antibiotic Antibiotic timing/redosingWarm air/blanket NormothermiaAppropriate hair removal
World Health Organization - Surgical Safety ChecklistBriefings, Crew Resource ManagementPreadmission
Patient Education – Hygiene, preop scrubsPreop risk factors/comorbidities review
Operating RoomChanges in skin prep, sutures, scrubs and sponge washesUse of ChlorhexidineImproved Wound Classification documentation
Surgical FloorsIV Training Wound Care ChampionsCulture Wounds
PDSA Cycles – Best Practices Audits
OR Initiatives – Breast Surgeries
Jan 2008 Feb 2009
Preop Antibiotic Administration
50% 76%
Antibiotic Timing 42% 100%
Normothermia 95% 100%
Warm Air/Blanket 17% 40%
Appropriate Hair Removal
90% 100%
Preop Antibiotic Administration
*Looking at compliance rate*Dates: Dec 1, 2009 to Jan 31, 2010 (n=176)*Sources of Data: Chart *Results:
(154/176) 87.5% of surgeries received preoperative antibiotics(24/154) 16% given 1 min before incision time(14/154) 9% given >1hr before incision time
No SSI SSI
No Preop Antiobiotics 14 8Preop Antibiotics Given 141 13
P-value: .001
No SSI SSI
No Preop Antiobiotics 24 12Preop Antibiotics Given within 1hr 131 9
P-value: .00008
Length of Stay Review
Colorectal Surgery Length-of-Stay
Observed Ra te: 41.82%E xpected Ra te: 26.48%O/E Ra tio: 1.58S ta tus : Needs Improvement
Length of Stay
Colorectal Surgeries
2005 2006 2007 2008 2009Acute Care Emergent Count 35 57 53 41 26
Average LOS 24 21 21 17 16Elective Count 77 68 80 91 37
Average LOS 15 9 10 10 10Acute Care Count 112 125 133 132 63Acute Care Average LOS 18 15 14 12 13
Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 200815 – 12 = 3
Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 20083 x 132 = 396 bed days saved in 2008
Examples of Data IntegrationGraph 10: Overall SSI O/E RatioJanuary 1, 2007 – December 31, 200795% Confidence Interval
Status:Hospital A: Needs ImprovementHospital B: Needs Improvement
Annual Incidence of Pneumonia fromFiscal Year 2005 to 2009
0
1
2
3
4
5
2005 2006 2007 2008 2009
Fiscal Year
Rate/100 Surgical Proced
Hospital A
Hospital B
Hospital C
- NSQIP Average
FHA Appendectomies (2005-2009)
2006 2007 2008 2009 Total
Acute 65% 49% 52% 40% 52%
Perfed 30% 48% 41% 33% 38%
Lap 5% 2% 7% 27% 10%
2009 Postop SSI SummaryWound Occurrence Site A Site B Site C
Superficial SSI 5.3% 3.4% 2.5%
Deep Incision SSI 0.7% 1.0% 1.2%
Organ/Space SSI 5.1% 1.2% 0.6%
Replicate Published StudiesTime of Day Effects
0%
2%
4%
6%
8%
10%
12%
00:30-
0:13
0
2:30
-3:30
4:30
-5:30
6:30
-7:30
8:30
-9:30
10:30-
11:30
12:30-
13:30
14:30-
15:30
16:30-
17:30
18:30-
19:30
20:30-
21:30
22:30-
23:30
Frequency of Surgical Start Time
Kelz, R., Tran, T., Hosokawa, P., Henderson, W., Paulson, C., Spitz, F., Hamilton, B., & Hall, B. (2009) Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study: Journal of the American College of Surgeons, 209-4, 434-445.
Time of Day Effects
Custom Fields
Literature reviewStandard definitionData entry formatSource of dataStudy duration – time dependent?TrialRevision of guidelines if needed
1. Anastomotic Leak2. True Wait Time3. True LOS4. Readmission5. DNR/Palliative Postop
AppendectomiesPerfed vs Non-perfed
2006-2009 casesn = 326
Perforated Non-perforatedDistribution 112 (34.36%) 214 (65.64%)Wait Time Door to Skin (Average) 5 hours 7 hoursLength of Stay 4 Days 2 DaysPostop SSI
SuperficialDeepOrgan/Space
5.4%3.4%3.4%
3.3%2.3%0%
Patient Feedback
• 33% average return rate per cycle• NSQIP clerk sorts and sends to Department Heads• Challenging issues -forwarded to Client Relations Office• Patient/Family meets with CRO and Chief of Surgery
Preop Albumin
Frequency of Preop Albumin Order for Emergent and Elective Surgeries from 2006 to 2009
0%
20%
40%
60%
80%
100%
2006 2007 2008 2009
EmergentElective
Wait Time ReviewsLap Chole
Average wait time: 78 hours
Appy
Data shows increased postop complications as wait time increases
Wait Time 0 to 4hrs 5 to 8hrs 9 to 12hrs >12hrs
Perfed 74(42%) 19(32%) 12(23%) 7(19%)
Nonperfed 104(58%) 41(68%) 40(77%) 29(81%)
Postop Complications 13(7.3%) 5(8.3%) 5(9.6%) 7(19.4%)
DNR Review
Examples of case reviews
Data Review for Planning and Decision Making
PACU-LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge)
Preadmission ClinicPatient feedback – patient education needsRisk assessments
OR ReorganizationRTO rates, length of surgery, time of surgery
Surgical UnitsDischarge by day of the week – staffingLOS and Outcomes
1South/Stepdown UnitAdmission criteria, LOS
Other hospital departments (housekeeping, dietary, pain service,etc)Patient Feedback
DVT/VTE Review
DVT/VTE ReviewID Score Risk1473 9 Highest Risk
1491 9 Highest Risk
3070 6 Highest Risk
3207 8 Highest Risk
3223 10 Highest Risk
4573 9 Highest Risk
5505 12 Highest Risk
5675 6 Highest Risk
5752 6 Highest Risk
1798 7 Highest Risk
2484 4 High Risk
3269 8 Highest Risk
3499 8 Highest Risk
3683 5 Highest Risk
3710 2 Moderate Risk
4155 8 Highest Risk
4892 4 High Risk
5325 7 Highest Risk
5528 5 Highest Risk
Jan 1, 2007 – Mar 31, 2010• 19 DVT/PE Cases• 3/19 (16%) RTO• 2/19 (10.5%) Died
Cost AnalysisCost of SSI after breast surgery: $ 4,091.00 USD ¹
Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD
Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrenceEmergent: 27.40 % Elective: 9.05 %
Cost of postop UTI: $ 3,535 CAD (excluding physician fees)Cost of Silver-coated catheter: $ 15.00Averted UTI in 3 months: 18
Outpatient Partial Mastectomy with Axillary Node Dissection (19302)
SMH NSQIP
2008 17.9 % 78.9 %
2009 10.3 % 77.3 %
Q42007
Q12008
Q22008
Q32008
Q42008
Q12009
Q22009
Q32009
Q42009
0%
2%
4%
6%
8%
10%
12%
14%
Mastectomy SSI Trend over Time
¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data
Cost Analysis
Do the math!
$$$
July 2010 Semiannual Report
Structure and Process Evaluation
The Wisdom of Crowds
Why the Many Are Smarter Than the Fewdiversity of opinionindependencedecentralizationaggregation
James Surowiecki
We vs Me
Who will speak up before I make a mistake?flatten hierarchy
Does Team Have Patient Safety Focus?checklist
How Do You “Stop The Line”?CUS words
Is There Fear Of Retaliation?need support from organization
Is Work Fun?We are doing a great job!
Data is accepted as validData is accepted as validNo finger pointing developedNo finger pointing developedChange was viewed as necessaryChange was viewed as necessaryCulture change underwayCulture change underway
Flattened hierarchyFlattened hierarchySafety and Quality articulated as goalsSafety and Quality articulated as goalsLearning Learning ““how to improvehow to improve””Patients notice changePatients notice changeIt works!It works!
ObservationsObservations
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