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In Search of the Holy Grail for Performance Improvement
ACS Midas +6/6/20005
C.J.Heller, MD FACS
Code Blue
ACS Midas +2005
Code Blue 2002
Individual review of selected code records for potential system failuresNo global statistics as to success rate as defined by discharged from hospital aliveMany unanswered questions.New ACLS Quidelines
Questions without Answers
% Codes which were Cardiac Arrests% Cardiac Arrests that were WitnessedCardiac Arrest Survival rate at DischargeSurvival Rate by Arrest statusResponse to ACLS guidelines
Keys to Success
Visible senior leadership commitmentSize of FocusPhysician ChampionRapid CyclePerfection, the enemy of good
Name TextAcct No Numeric IV Access Single Select YesDate of Event Date NoLocation Single Select Present at Onset
Critical Care IV Access Time NumericEDMed/Surg ECG Monitor Single Select YesOutpatient NoDiagnostics Present at OnsetOthers ECG Monitor Time Numeric
Witnessed Y/N Intubation Single Select YesMonitored Y/N No
Present at OnsetInitial Conscious Y/N Intubation Time NumericInitial Breathing Y/NInitial Pulse Y/N Defibrillation Y/N
Defibrillation Time NumericInitial Rhythm Single Select
V-Fib, Pulseless V Tach Epinephrine Y/NPulseless Electrical Activity Epinephrine Time NumericAsystoleBradycardia Code Duration NumericPerfusing rhythm Code Disposition Single Select Critical CareUndocumented Unit
ExpiredCode Time NumericCPR Y/NCPR Time Numeric
Yes
Yes Yes NoAt the time of the code, was the patient
On a cardiac monitor? Conscious? Breathing spontaneously? With a palpable pulse?
Yes No Yes No Yes No Yes No
Was an airway established? Type of airway: Time airway established:No Present at onset ET L Trach B Other:
Was CPR started?(CPR is defined as bagging &/or chest compressions)
Time CPR started: Time placed on the code cart monitor:
Yes NoInitial cardiac rhythm:
(Please circle)
Ventricular tachycardia, pulseless Pulseless electrical activity Perfusing rhythm
Bradycardia w/inadequate perfusion Ventricular fibrillation
Ventricular tachycardia, with pulse Asystole Date of Code:
Patent IV access present at time of code? Y / N If not, time IV started: Defibrillated? Y / N
Time of 1st defibrillation:
Rhythm defibrillated or cardioverted: Given Epinephrine? Y / N
Pulseless VTTime of 1st dose:
Time code ended: Did the patient survive the code: Y / N VT w/pulse
VF PEA
Other
Problems with equipment or delays in obtaining equipment? (describe)
Problems with supplies or delays in obtaining supplies? (describe)
Problems with personnel? (describe)
Data Sources
PBX LogCode Blue AuditsMedical Record CodingRespiratory Therapy
Midas Code Blue Calls 2004
0.000
0.005
0.010
0.015
0.020
0.025
0.030
0.035
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Rat
e
Location of Code Blue Calls2004
Count of PatientLOCATION2 TotalMed-Surg 41 19.5%Diagnostics 21 10.0%CCU 1 0.5%Dialysis 6 2.9%ED 51 24.3%ICU 81 38.6%Perioperative 9 4.3%Grand Total 210
Inpatient Code Blue
CodesPatients
Cardiac ArrestNo Yes
Codes CodesPatients Patients
WitnessedNo Yes
Codes CodesPatients Patients
# of patients detailed below. The last codeis noted for patients with multiple codes
Discharge Alive Survived Code Code Code Survived Code Discharge Alive
Ventricular Fib
Pulseless VT
PEA
Asystole
Bradycardia
Inhouse 1/03-12/04
Code Blue
290 Codes260 patients
Cardiac ArrestNo Yes
120 codes 165 codes123 patients 155 patients
WitnessedNo Yes
27 codes 138 codes27 patients 128 patients
# of patients detailed below. The last code is noted for patients with multiple codes
Discharged Alive Survived Code Survived Code
Discharged Alive
0 2 Ventricular Fib 23 17 15
0 Pulseless VT 18 12 8
0 2 5 PEA 25 9 1
0 17 Asystole 36 17 4
0 2 3 Bradycardia 24 14 6
0 Other 2 3 0
26.6%
81.6%
63.4%
30%
40%
50%
60%
70%
80%
90%
100%
P-Chart (0.001 Limits)
Christopher Memorial Hospital% Code Arrest Calls Using the Designated "911" Phone Line
December 2002 - January 2005Source: Inpatient Satisfaction Survey
Regression AnalysisR-Square: 1.0P value: < 0.05Increasing at a rate of 5 % per month
Christopher Memorial Hospital% Code Audit Sheets and / or Copy of Code Charting Received
December 2002 - January 2005
80.7%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
P-Chart (0.001 Limits)
RNS
Midas Acute Care Mortality Rate 2002-04
0.00
0.01
0.01
0.02
0.02
0.03
0.03
0.04
0.04
0.05
Jan-02
Mar-02
May-02
Jul-02
Sep-02
Nov-02
Jan-03
Mar-03
May-03
Jul-03
Sep-03
Nov-03
Jan-04
Mar-04
May-04
Jul-04
Sep-04
Nov-04
Month
Rat
e
Rapid Response Team
2005
Rapid Response
“Research shows that virtually all critical inpatient events are preceded by
warning signs on an average of 6.5 hours.”
Rapid Cycle Schedule
12/04 Presentation and approval of Senior Leadership1/05 Meeting of CONs to establish ownership2/05 Endorsement of concept by MECs3/05 Initial pilot project begun! 7-7
Rapid Response Work Group
Senior Nurse LeaderPhysician ChampionRespiratory TherapistICU Charge NursePatient Safety Coordinator
Mission Statement
Mission Statement: To establish a team of healthcare professionals that will be available to rapidly respond to acutechanges in patients’ clinical condition and to initiate diagnostic and therapeutic interventions while contacting the patient’s primary care provider.
Needs Analysis
Mission StatementFocus: Advanced Clinical AssessmentMedical Staff Buy-in : Rapid CycleDocumentation FormStanding Orders
Flow
Trigger ART
Attending Advanced Clinical Assessment
SBAR
Delay
Transfer
Standing Orders
Advanced Clinical Assessment Team Standard Orders V5
Date Time Transfer to ___________________
Diagnostics ( STAT )Pulse OximetryArterial Blood Gases12 Lead EKGBlood GlucoseCBC Complete Metabolic Panel Point of Care Na K Hgb/Hct Glucose CreatininePT/PTTMagnesium Phosphorus LevelType & Screen Type & crossmatch 2 units Packed cellsCK isoenzymes Troponin every 6h x 3Culture Sputum Urine Blood ( line___/ Peripheral___ ) Serum LactatePortable Chest X-ray ( STAT)
InterventionsEstablish IV access NaCl @ 25 ml every hour TKOInsert Foley Catheter to gravity drainageInsert NG Tube to low intermittent suctionTranscutaneous Pacing pad placementNT/oral tracheal suctioningTitrate FIO2 Nasal Cannula @ __________ Venti-mask @ __________ 100% Non-Rebreather Oximizer @ __________Titrate FIO2 to keep O2 saturation 88-92% for CO2 retention, >92% otherwiseNebulizer Albuterol unit dose (2.5mg in 3ml NaCl) may repeat prn
MedicationsAtropine 0.5-1mg IV over 1 min. may repeat onceNarcan 0.4 mg IV over 15 sec.Dextrose 50% IV ( 25gms / 50ml)Glucagon 1mg IM ( May repeat in 20 min-if no response must give Dextrose 50% IV)Nitroglycerin 0.4 mg SL (may repeat x 2 every 5 min.)Dopamine (400mg/250ml D5W), titrate MAP>65 or SBP>90 0.5-20mcg/kg/minFluid Bolus - 500ml NaCl over 30 min ( May repeat x 1)
Physician SignaturePatient ID Label
Time BP Pulse RR Temp O2 Sat
Date Unit Provider
Unit Code Status
Adm Diagnosis
Principal Procedure
Date of Procedure
SituationCall TimeArrival TimeDeparture
Background
Assessment
Recommendations
Critical Care Nurse
Respiratory Therapist
FU Note Nursing Supervisor
Decrease in urine output < 30 ml/hr
Staff is worried about patient
Pain
Falling SpO2
Change in level of consciousness
Change in Blood Pressure by 20%
Change in Pulse by 20%
Respiratory Rate >24 or <8
ACAT Documentation Form V5
Keys to Success
Visible Senior Leadership CommitmentPhysician ChampionEnd User InvolvementRapid CyclePerfection, the enemy of goodPhysician Ownership
Measures of Success
Decrease in cardiac arrestsDecrease in cardiac arrests on the med-surgunitsDecrease the failure to rescue rateDecrease the acute care mortality rateOverall decrease in Code Blue calls
Location of Code Blue Calls2004
Count of PatientLOCATION2 TotalMed-Surg 41 19.5%Diagnostics 21 10.0%CCU 1 0.5%Dialysis 6 2.9%ED 51 24.3%ICU 81 38.6%Perioperative 9 4.3%Grand Total 210
Rapid Cycle 24/7
1/24/05 – 4/1/05
Complications
2005
Complication Rate
Severity Adjusted ?Comparative DataVolume Sensitive
Statistical SignificanceClinical Significance
More Common EventQuality of Measure: FairBarriers: Data not Available
Complication ???
Principal Diagnosis : AMI
Secondary Diagnosis :428.1 Left Ventricular Congestive Heart
Failure
Concept
At the time of medical record creation of the discharge abstract each final
diagnosis will be labeled as present or not present at the time of admission
to the hospital.
Value Analysis
Identify diseases and procedures with specific complications for PI activitiesElectronic Identification of medical records for peer reviewFeed back to physicians regarding complications and complication ratePhysician profile for reappointment
Complications
ReportingOccurrence Screens/TriggersCoded ComplicationsAHRQ Patient Safety Indicators
Present/Absent on Admission
Current Coding
“ Current complication algorithms identify many cases where the condition was actually present on
admission.This fact, coupled with the known variability in coding between institutions, makes comparisons between hospitals on many of the complications problematic. Collection of the
present-on-admission flag significantly reduces the noise in monitoring complication rates”
Complication is a Diagnosis
Not Present on Admission
Complication Rate (Diagnoses Not Present on Admission)
Count of Account No.Not POA Count Total
0 7915 14.9% Complication Rate1 5682 300 3511 Total # Complications3 2144 1225 656 407 318 329 15
10 4Grand Total 9306
Complications by Discharge Disposition
Count of Account No. DC DispNot POA Count AMA EXPIRED Home Other Rehab SNF Grand Total
0 142 101 6839 537 30 238 78871 8 20 426 67 7 40 5682 2 25 214 37 3 19 3003 2 13 147 36 2 14 2144 12 80 14 4 12 1225 1 14 34 8 2 6 656 9 15 12 4 407 7 15 6 3 318 6 16 7 1 2 329 1 7 6 1 15
10 2 2 4Grand Total 155 210 7795 730 49 339 9278
8.4% 51.9% 12.3% 26.4% 38.8% 29.8% 15.0%
Major Complication Rate/1000
PE 1.5Pneumonia 6.7Acute Renal Failure 7.2Sepsis 3.2DVT 6.8Stroke 1.2AMI 2.8CHF 3.2
32.6
32.6/1000 3.2%
Has the Time Arrived ?
Mayo Clinic 1990CaliforniaNew YorkIndividual HospitalsUB 04
Barriers to Implementation
New ConceptMultiple Silos involved
Medical RecordsQuality ManagementInformation SystemsCredentialing
Vendor Cooperation*** Pain with no Gain
Keys to Success
Senior Leadership commitment
Driver
Medical Record Director who could see the big picture
Vendor commitment
Conclusion
The timeline for this project was approximately 12 months as the HIS vendor took at least 9 months to add
the field necessary to capture the data to the software.
Complications
Indicator 2002 2003 Total Specialty
Complication Rate 13.8% 12.8% 13.2% 14.1%Major Complication Rate 4.2% 3.9% 4.1% 3.4%
AMI Complication 0 1 1 8Pneumonia Complication 1 2 3 56Congestive Heart Failure Complication 2 0 2 20Sepsis Complication 4 2 6 71Ischemic Stroke Complication 0 1 1 15Acute Renal Failure Complication 1 0 1 41PE Complication 0 1 1 6DVT Cmplication 2 2 4 56
Pulmonary Embolus as a Complication 415.11,415.19
Hospital A15 Prim. PE15 PE Co - morbidity11 POA
17 PSI10 POA
4 PE Not POA
Hospital B23 Prim PE6 PE Co - morbidity 4 POA
9 PSI 6 POA
2 PE Not POA
Sepsis
ACS Midas+ DV2005
Institute for Healthcare Improvement
100,000 Lives Campaign
Focus 2005Rapid Response TeamAcute Myocardial InfarctionAdverse Drug EventsCentral Line InfectionsSurgical Site InfectionsVentilator Associated Pneumonia
Midas Primary Sepsis Mortality 02-04
Numer Denom RateCDB 4387 24817 17.68%Site 22 63 34.92%
Numer Denom RateCDB 6226 35312 17.63%Site 25 69 36.23%
Numer Denom RateCDB 8751 48361 18.10%Site 28 82 34.15%
2002
2003
2004
Midas GeneralIncidence of Sepsis, Any Diagnosis
Count of Account No.Years End Dt Total2002 Qtr1 37
Qtr2 36Qtr3 53Qtr4 55
2003 Qtr1 54Qtr2 53Qtr3 58Qtr4 72
2004 Qtr1 61Qtr2 45Qtr3 43Qtr4 56
2005 Qtr1 52Grand Total 675
Midas GeneralPrimary Sepsis
Count of Account No.DC DispYears End Dt AC Expired Home Hospice LTC Other Rehab SNF Grand Total Mort. T.Mort.2002 Qtr1 9 3 1 2 15 60.0% 60.0%
Qtr2 2 12 1 1 16 12.5% 18.8%Qtr3 4 10 2 1 1 1 19 21.1% 31.6%Qtr4 8 4 1 2 15 53.3% 60.0%
2003 Qtr1 9 7 1 1 18 50.0% 50.0%Qtr2 1 2 6 1 1 11 18.2% 27.3%Qtr3 1 7 8 2 1 3 22 31.8% 40.9%Qtr4 1 8 4 1 6 20 40.0% 45.0%
2004 Qtr1 1 11 7 1 1 1 2 24 45.8% 50.0%Qtr2 8 10 1 2 1 1 23 34.8% 39.1%Qtr3 5 7 1 3 16 31.3% 31.3%Qtr4 5 9 4 1 1 20 25.0% 45.0%
2005 Qtr1 1 4 7 3 3 3 21 19.0% 33.3%Grand Total 5 82 94 17 6 4 9 23 240 34.2% 41.3%
Midas GeneralMortality Rate As related to Age All Sepsis
Count of AccoC DispAge AC Expired Home Hospice LTC Other Rehab SNF Grand Total10-19 1 1 0.0%20-29 1 4 9 1 1 16 31.3%30-39 1 4 16 2 1 1 25 16.0%40-49 2 17 25 1 6 5 6 62 27.4%50-59 4 26 30 3 2 1 2 6 74 39.2%60-69 4 28 41 4 4 1 5 10 97 33.0%70-79 6 51 45 10 2 4 12 17 147 41.5%80-89 5 41 29 12 1 2 8 21 119 44.5%90-100 1 7 3 3 1 1 16 62.5%Grand Total 24 178 199 33 12 14 34 63 557 37.9%
Midas GeneralPrimary Sepsis Organism ID 02-04
Count of Account No.DX1 Description2 TotalSepsis without ID Specific Organism 123 51.3%E COLI SEPTICEMIA 34 14.2%H. INFLUENAE SEPTICEMIA 1 0.4%PNEUMOCOCCAL SEPTICEMIA 6 2.5%PSEUDOMONAS SEPTICEMIA 8 3.3%SERRATIA SEPTICEMIA 1 0.4%STAPHLOCOCCUS AUREUS SEPTICEMIA 31 12.9%STAPHYLOCOCCAL SEPTICEMIA, NEC 7 2.9%STAPHYLOCOCCAL SEPTICEMIA, NOS 2 0.8%STREPTOCOCCAL SEPTICEMIA 27 11.3%Grand Total 240
Midas GeneralPrimary Sepsis Organism ID 02-04
Count of Account No. DC DispDX1 Description2 AC Expired Home Hospice LTC Other Rehab SNF Grand TotalSepsis without ID Specific Organism 3 55 35 10 2 1 4 13 123 52.8%E COLI SEPTICEMIA 3 26 2 1 2 34H. INFLUENAE SEPTICEMIA 1 1PNEUMOCOCCAL SEPTICEMIA 2 3 1 6PSEUDOMONAS SEPTICEMIA 3 4 1 8SERRATIA SEPTICEMIA 1 1STAPHLOCOCCUS AUREUS SEPTICEMIA 1 9 8 3 3 1 2 4 31STAPHYLOCOCCAL SEPTICEMIA, NEC 3 3 1 7STAPHYLOCOCCAL SEPTICEMIA, NOS 1 1 2STREPTOCOCCAL SEPTICEMIA 1 5 13 2 1 2 3 27 29.1%Grand Total 5 82 94 17 6 4 9 23 240
Midas GeneralPneumonia with Sepsis
Count of Account No. DC DispYears End Dt EXPIRED Home Hospice SNF Grand Total2002 Qtr1 2 2
Qtr2 1 1Qtr3 1 1Qtr4 1 1
2003 Qtr1 1 1 2Qtr2 1 1Qtr3 1 1Qtr4 3 3
2004 Qtr1 1 1Qtr4 2 1 3
2005 Qtr1 1 1Grand Total 8 6 1 2 17 52.9%
Midas GeneralSepsis as a hospital aquired complication
Count of Account NDC DispYears End Dt AC Expired Home Hospice LTC Other Rehab SNF Grand Total2002 Qtr1 1 4 2 1 2 10
Qtr2 3 4 1 3 11Qtr3 1 3 12 1 1 2 2 22Qtr4 9 6 1 3 2 21
2003 Qtr1 6 7 1 3 17Qtr2 1 9 6 2 2 1 1 22Qtr3 1 2 10 1 1 2 17Qtr4 3 7 10 1 2 3 5 31
2004 Qtr1 2 5 6 1 3 4 21Qtr2 2 5 3 1 3 3 4 21Qtr3 11 9 1 1 1 3 26Qtr4 3 12 6 2 2 6 31
2005 Qtr1 3 5 12 1 1 1 2 1 26Grand Total 17 81 93 14 5 7 23 36 276 34.4%
Barriers to Sepsis Management
Early Recognition of Presumptive DxRecognition of the degree of severityEarly central line placementRapid admission to Critical Care UnitAggressive Fluid ResuscitationLack of Physician to Physician CommunicationScvO2 need
Key Strategies for Success I
Medical Staff Buy-inPhysician ChampionKey Physician Participants
Emergency DepartmentHospitalistsInfectious DiseaseChief Medical Officer
Key Strategies for Success II
Key Nursing ParticipantsCritical CareEmergency departmentRapid Response Team
Understanding the barriersSegmenting the problemRapid cyclePerfect, the enemy of good
Primary Sepsis I
RecognitionRisk AssessmentFluid ResuscitationAntibioticsSource ControlVentilator Management
Primary Sepsis II
Drotrecogin AlfaLow Dose SteroidsGlycemic ControlChemical VTE ProphylaxisStress Ulcer Prophylaxis
Sepsis PathwayPrimary Sepsis
1 Patient Admitted to ED
2 Presumptive Diagnosis of Sepsis
* Establish large bore IV access* Appropriate cultures* Antibiotics within one hour of
presumptive diagnosis
3 Severe Sepsis
* MAP < 65* Lactate > 4
4 Initiate Sepsis Fluid Resuscitation Guidelines
5 Admit to ICU STAT
* Notify attending physician of admission policyof patient having to be seen within 60 minutes
* Notify attending physician of need for physician to call physician for immediate central line placement Between 6:00 AM and 12:00 midnight call anesthesiabetween 12:00 and 6:00 AM if anesthesia unavailablehave central line placement done in ED
SEPSIS Pilot Guidelines v10 5/26/05
Presumptive Diagnosis of Sepsis
Obtain Large Bore IV Access and begin normal saline at 1000 ml every hourVital Signs q 15 min
STAT Blood Culture (blood culture x2 15 min apart and culture Panel from any venous access device plus serum lactate level)Culture urine, sputum and any potential site of infection ,swab nares for MRSA STAT Chest X-ray and EKGSTAT CBC, Blood type and screenSTAT Complete chemistry profile and urine analysisSTAT INR,PT,PTT List all allergies to antibiotics and reaction type Obtain all cultures prior to initiating antibiotic RX Initiate antibiotic Rx within 1 hour of Presumptive DX of Sepsis , 1st Dose STAT
Maintain O2 Saturation > 95% unless concern of CO2 retention, then obtain ABGs and consider respiratory therapy consult
If MAP < 65 and/or Serum Lactate > 4, treat for septic shock, initiate active fluid resuscitation
Consider Infectious Disease Consult: Physician to physician requestAdmit inpatient or transfer ICU StatInsert Arterial Line with MAP every 15 min until MAP > 70 then every 30 minFoley with Temperature probe to CD and record hourly outputInsert Central Line with continuous CVP measurement, if available Central line insertion physician to physician request
Active Fluid Resuscitation Guideline
If CVP < 4mm Hg, give 500 ml 5% Albumin (25 grams) over 15 min x 1, and give 1000ml normal saline bolus every 30 min until CVP 8-12If CVP >4mm Hg but < 8mm Hg, give 500 ml normal saline bolus every 30 min until CVP 8-12mm HgWhen CVP 8-12mm Hg, give IV normal saline at 150 ml every 1hour
If MAP is < 65 and HR < 120 after 1 hour of active fluid resuscitation, begin norepinephrine drip 2 - 20 mcg/min and titrate to MAP 65-100If MAP is < 65 and HR > 120 after 1 hour of active fluid resuscitation, begin phenylephrine 40-200 mcg/min and titrate to MAP 65-100
If central venous O2 saturation < 70 and Hct < 30/ Hgb < 10, transfuse packed red cells to HCT > 30 and Hgb > 10If central venous O2 saturation < 70 and Hct > 30 / Hgb > 10 , begin dobutamine 2.5-20 mcg/min if HR < 100 and SBP > 100
At 6 hours following active fluid resuscitation, calculate APACHE 2 scoreSTAT F/U serum lactate at 6 hours after onset of fluid resuscitation
Severe Sepsis Bundle 6 Hour
Presumptive Dx is made within 2 hoursSerum Lactate measuredAntibiotics administered within one hour of presumptive Dx
Severe Sepsis with Shock Bundle: 6 Hour
Presumptive Dx within 2 HoursAntibiotics within 1 hour of DxImmediate fluid resuscitationminimum 20 - 40 ml/kg
* Vasopressors for MAP < 65CVP and ScvO2 obtainedInotropes and/or PRBCs SVC sat <70% after CVP > 8 mm HgSteroids if continued need vasopressors
Severe Sepsis 24 hour bundle
Glucose control < 150 mg/dlTidal volume of 6ml/kg and plateau pressures on average <30 cm H2O for ventilated patients with ARDSDrotrecogin alfa using local guidelines
How are we doing?
2005
Code Blue Rate Midas
Midas General Acute Care Mortality Rate
Primary Sepsis Mortality Rate Midas General Hospital
0
10
20
30
40
50
60
70
Jan-Mar2002
Apr-Jun2002
Jul-Sep2002
Oct-Dec2002
Jan-Mar2003
Apr-Jun2003
Jul-Sep2003
Oct-Dec2003
Jan-Mar2004
Apr-Jun2004
Jul-Sep2004
Oct-Dec2004
Jan-Mar2005
Apr-May2005
Quarter
Mor
talit
y R
ate
Failure to Rescue Midas
Midas General Failure to Rescue /1000
0
50
100
150
200
250
Jan-Mar2002
Apr-Jun2002
Jul-Sep2002
Oct-Dec2002
Jan-Mar2003
Apr-Jun2003
Jul-Sep2003
Oct-Dec2003
Jan-Mar2004
Apr-Jun2004
Jul-Sep2004
Oct-Dec2004
Jan-Mar2005
Apr-May2005
Quarter
Rat
e/10
00
Midas General Hospital Code Blue Rate per 1000
0.0
5.0
10.0
15.0
20.0
25.0
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
Month
Rat
e/10
00
The Holy Grail
IssueChampionSenior Level FacilitatorFragmentationRapid CycleOwnership
ChangeBarriersPerfectionStyles
