House Care Convention: A Dialogue with Joint Fee

This text is delivered to you by the Joint Fee. The article relies on a…

House Care Convention: A Dialogue with Joint Fee

This text is delivered to you by the Joint Fee. The article relies on a panel dialogue that befell throughout a stay Q&A session with Jason Vanhoose, Affiliate Director of Enterprise Improvement for the House Care Accreditation Providers with the Joint Fee; Josie Rhoades, VP of Scientific Operations at Brightstar; and Kate Proctor, Deputy Normal Counsel for AccentCare. The panel befell on the House Care Convention in Chicago held on December 9, 2021. The panel has been edited for size and readability.

Jason Vanhoose: At the moment, we’re going to be speaking about how information, tradition, and partnerships are altering the way forward for dwelling care. My title is Jason Vanhoose from the House Care Accreditation Providers with the Joint Fee. At the moment, we shall be talking with Josie Rhoades, from BrightStar, and Kate Proctor, from AccentCare.

Vanhoose: A bit of bit about myself. I’m lately new to the Joint Fee. I’ve been a nurse for 25 years and spent 18 years as a scientific within the emergency room. For the final 10 years, earlier than becoming a member of the Joint Fee, I’ve been a discipline nurse, a director of operations and a scientific supervisor with one of many largest dwelling care suppliers within the nation. In my time as a nurse, we’ve seen so many modifications within the business, not solely in a scientific perspective however in addition to inside dwelling care.

After we have a look at information, Josie, how has BrightStar tailored to the completely different information modifications lately? How do you see that altering sooner or later?

Josie Rhoades: I feel whenever you discuss information in dwelling care, one of many issues that we at all times have bother with is getting correct information. We’re reliant on our employees, our shoppers, and our sufferers to provide us that info that we are able to enter it. We don’t have the power to seize claims information on every little thing. I feel one of many focuses is absolutely how can we get correct information?

On the scientific end result aspect, I feel we additionally should be taking a look at how we validate our information. We’re getting individuals telling us, I went to the hospital, let’s put that in, that’s our scientific outcomes. At BrightStar, one of many issues we simply did, and this was not by design, we labored for the corporate known as Avalere and the press launch really got here out at present, which was a examine that validated our scientific outcomes.

They took a cohort just like ours and checked out price utilization one 12 months earlier than we have been taking good care of that consumer in a single 12 months after. We noticed large financial savings in sure situations, so go forward and check out that, however that’s a kind of issues that I feel is absolutely necessary. We have now all this nice high quality, however how do you validate that? Specializing in validating a few of that after which I feel taking a look at information sooner or later is it’s not sufficient to simply pull what are our hospital readmissions? What are ED visits?

It’s a few of these issues, what does treatment adherence seem like? What’s the time to inform you of a change of situation? What have been these interventions on change of situation? At BrightStar, we’re taking a look at change of situation, among the outcomes that we’re taking a look at capturing is, one, was there a change of situation? If there was, what was executed about it? Did our nurse that’s offered oversight contact the household, educate the caregiver? Capturing not solely what that intervention was, however what was the time of intervention?

Then have a look at, previous that, was there an ED go to? Was there hospitalization? We’re digging deeper into a few of these scientific outcomes to simply higher perceive our business as a complete. If we have a look at a few of these insurance policies, the best way I consider it’s if I’m taking a look at modifications of situation in a scientific sense for these interventions that have been captured, let’s say, earlier than 24 hours, did we’ve higher outcomes? Do I then want to alter my coverage? We have a look at our insurance policies to imitate that. We’re then standardizing our care on greatest observe, in order that’s one other factor I feel for information.

We have to get higher at accumulating the info. We have to standardize our information. We have to validate our information. We have to do so much with our information.

Kate Proctor: It’s humorous as a result of Josie is on the scientific aspect and I’m clearly a lawyer. I used to be with Seasons Hospice & Palliative Take care of seven years and we have been merged with AccentCare late final 12 months. I moved extra into the authorized division, however I used to be working high quality and doing so much with compliance. Now, we’re attending to do enterprise threat administration, which I like. It’s so attention-grabbing however it’s the same sorts of issues, the place Josie will take it and truly enhance high quality, which is what you completely need.

I then take that and say, “See? We shouldn’t have been sued for this,” or, “There wasn’t a normal of care that was violated,” or, “If it’s a authorities investigation. See these are the issues that we do to enhance our care, to ensure that there’s no fraud, waste or abuse,” and I can take what Josie’s counterpart at our group does and say, “They’re validating all of this information. I can show to you that we don’t have any fraud, waste or abuse,” as a result of we’ve all of those stories. They’re validating they usually’re wanting on the insurance policies to make issues higher.

It’s actually attention-grabbing that every little thing that the scientific group and the standard groups do with naked information is enormously useful for me and makes my job very simple, though I’m nonetheless needed. Don’t stroll into your lawyer’s places of work and be like, “Sure, we don’t want you anymore.” It’s enormously useful. It’s a lot simpler to enter a gathering with the Division of Justice, for instance, and say, “Sure, let me do a complete presentation. Right here’s all the stories that we’ve to show to you that that was not regardless of the allegation was, wasn’t occurring, couldn’t have been occurring.”

It’s extremely helpful for us too within the threat administration division, the authorized departments that we’ve correct information that we’ve any information, frankly, and that we act on it. I feel one of many issues that dwelling care hasn’t at all times been nice at is definitely performing on no matter information they’re accumulating. In case you have a complete bunch of information, however you’re not doing something with it that you could find, it’s very simple as a plaintiff’s council or the federal government to return in and say, “Hey, produce for me all of this information that you’ve got sitting round.”

The federal government will see it and in the event you haven’t executed something with it, that’s actually problematic. It’s not sufficient simply to be gathering the info. It’s a must to take that subsequent step of performing on no matter it says. It’s not fast. Change takes a very long time, however after you have that information, you may’t sit on it.

Rhoades: Which is attention-grabbing whenever you discuss performing on a few of that information. House care doesn’t have the perfect observe. We don’t have good analysis. We don’t have these issues. I feel the place we actually do want to begin performing on information is our personal inside information. Begin sharing or benchmarking it, that’s the place we’re going to actually see that high quality throughout the business begin enhancing and bettering.

Proctor: It’s additionally like why we do these sorts of conferences, why Josie and I hang around is as a result of it’s useful to know what your counterparts are doing as a result of there aren’t articles, there aren’t these huge quantities of information on how it is best to implement no matter situation it’s that you just’re attempting to resolve. With the ability to share, “Hey, that is the info we’re accumulating, that is what we’re seeing, are you guys seeing something comparable?” Not being afraid of sharing that. I feel perhaps it’s not a waste although, however no less than in hospice and typically in dwelling care, it’s good the place everyone’s striving towards the identical factor.

Rhoades: High quality is on the prime of that record.

Proctor: Completely.

Vanhoose: Proper. When speaking about information, there’s a lot information on the market. Old skool, after I first began, it was all paper documentation. Now, it’s all laptop documentation. Once you’re taking a look at pulling the info from BI to HCAHPS to Star Scores, how troublesome is that? How has the change in information from previous to current? How has that helped with BrightStar’s care in decoding the info and what are the constraints that it causes on you?

Rhoades: I feel at BrightStar, we’re actually fortunate. We personal and handle previous to our EMRs. I’ve the power to tug a whole lot of information from there and make my very own stories and issues. There are nonetheless some very handbook issues we monitor. We have now over 350 places of work, a few of them are monitoring issues nonetheless in Excel spreadsheets and issues like that. A few of this can be a very handbook course of. I feel getting extra in the direction of a few of that BI goes to be needed as a result of it does, it takes a whole lot of assets. It takes a whole lot of time.

Anyone that works in well being care, if it’s one thing that takes a whole lot of time, you’re simply not going to do it. It will get to that time. One of many issues I completely love with the Joint Fee is the SAFER Dashboard. I have a look at it as a franchisee taking a look at BrightStar as its entirety. I can have a look at what findings we’ve been hit with, what our prime 10 are, and I can have a look at us versus our rivals.

It’s one other means I can validate that we’re the next high quality as a result of we’ve much less findings than our rivals, but in addition in a scientific sense, I do know the place I must dedicate assets to, I can have a look at various things, what academic factors I discuss. Each single month we’ve a director of nursing month-to-month assembly that we’ve individuals get on and we use that information. Here’s what we’re discovering. Right here’s what’s coming down. Right here’s what that discovering is. It’s a means of actually understanding not solely BrightStar as a complete however then they will use that themselves and it’s a full BI instrument. It’s actually, very easy to make use of.

Vanhoose: You probably did point out the SAFER information, how a lot time has that saved you guys?

Rhoades: I don’t even know that I might estimate it as a result of, previous to that, we have been all conserving it in a large Excel spreadsheet, of when the surveys have been, what the findings have been, who the surveyor was, and it actually was manually monitoring that. Anyone is aware of who handbook tracks it. You may have one busy week and also you let it fall by way of. Then in some unspecified time in the future, you’re going to must undergo three or 4 months of information and enter all of that since you procrastinated for 4 months. It saved an immense period of time.

Vanhoose: Kate, by way of AccentCare, how do you guys interpret the info? What are among the challenges that you’ve got had capturing the info? You talked about by way of high quality and it’s not documented, it wasn’t executed and issues of that nature. How has that helped you guys?

Proctor: It’s helped us enormously, I feel in a few other ways. Not simply from the danger administration perspective however Josie’s speaking about their proprietary EMR and I’m so extremely jealous. As soon as we’re up and working, then we are able to oftentimes write our personal stories out of that information so we are able to accumulate a complete bunch of various issues. Once I’m taking a look at from a threat administration perspective what does this seem like, we’ve to have our IT group pull stories and create stories in a whole lot of instances.

That saves me a whole lot of time and our clinicians can really do scientific work whereas the administration is definitely taking a look at and gathering the info, which is enormously useful since you need your clinicians doing scientific work, executing on the plan. That’s been enormously useful to us. I feel the opposite means we used it’s, as an legal professional, I’m very concerned in negotiating contracts with companions. For instance, we’ve inpatient models at hospitals everywhere in the nation.

It has been enormously useful to have the ability to stroll into a gathering with hospital executives and say, “We’re offering high-quality care. When you allow us to have a unit in your hospital, that is how we’re going to enhance your outcomes, and right here’s how I can show it as a result of at different hospitals, the place we’ve this, we’ve all of this information on lowering readmissions, mortality charges,” these sorts of issues. It’s simply enormously useful to have the ability to stroll in with that spreadsheet or sheet, truth sheet and say, “Do you need to speak to our different hospital executives as a result of they’ve had terribly good experiences?”

With the ability to go into a gathering with hospital executives who do have a whole lot of information and act on a whole lot of information is extremely useful in creating these partnerships after which actually long-lasting as a result of then their boards, clearly, need to see how their outcomes are progressing. Quarterly, we’ve to breed these outcomes which hospital however after you have the framework for it, and you understand what hospitals are in search of, it’s fairly simple to run and hold monitor of quicker in order that if there does turn into a difficulty the place perhaps there’s a care subject, you may reply to it way more shortly and hopefully earlier than the following quarterly assembly.

Rhoades: I additionally assume a kind of two is speaking to your completely different companions and referrals and issues like that. Folks pays for high quality.

Proctor: 100%

Josie: When you can show that high quality, you will get higher charges.

Proctor: Nursing properties significantly particularly whenever you stroll in and say, “Take a look at how properly we are able to scale back your readmissions,” as a result of that’s additionally what they’re in search of to get referrals. With the ability to present your companions, your referral sources, how one can assist them enhance their high quality has been a extremely, actually useful instrument for us by way of rising and increasing.

Vanhoose: As a house care nurse, one factor I at all times stated was I had this saying and anyone that is aware of me and would ask me what that will be is that in the event you don’t present high quality, there isn’t any amount.

Proctor: That’s proper.

Vanhoose: The amount will come so long as you present high quality. If we don’t have that amount, then we don’t have a enterprise. Let’s discuss partnerships. Partnerships are key they usually’re important transferring ahead. Kate, what sort of partnerships are you in search of? How are you leveraging these partnerships going ahead?

Proctor: We’re additionally in search of companions who’ve information and can share it with us. You’re solely pretty much as good as the knowledge that you’ve got. After we’re taking a look at even a house well being associate together with your hospice is seeing how their information reveals that they’re offering prime quality care. At nursing properties, it’s an enormous deal as a result of finally, you don’t need to be chargeable for one thing. We don’t need to be liable in the event that they’re not offering high-quality care. They don’t need to be chargeable for offering poor care, clearly.

With the ability to present them, “Hey, listed here are outcomes,” as a result of you understand any of you who’ve ever talked to a referral supply is aware of that the factor they bear in mind is the dangerous end result. That’s what they are going to bear in mind. They received’t keep in mind that household who known as and stated, “I cherished my hospice nurse a lot.” That’s pretty, however what they bear in mind is, “That hospice nurse was so horrible and by no means confirmed up.” That’s what they bear in mind. That’s what everyone remembers.

With the ability to say that was a one-off or there was an evidence, “Do service restoration for that incident.” Additionally, say, “Look, the overwhelming majority of our outcomes are actually good,” if assuming that’s true. If it’s not true, repair it.

Vanhoose: Josie, how has that affected BrightStar’s care and the place you guys are wanting now, and the place you’re looking sooner or later by way of companions?

Rhoades: You possibly can have a look at it a number of other ways. I feel I can have a look at it as inside since we’re a franchise system. I see our independently owned places of work as our companions. How do I work with them? How do I assist them give the perfect scientific high quality as a result of that then helps us all at BrightStar as a complete? That results in higher outcomes, higher partnerships, higher charges. Helps us with standardization so we’re performing extra like a community fairly than every individually owned and operated. I additionally have a look at that once we discuss exterior companions.

The quantity of individuals I speak to at present about issues has been fabulous to listen to their opinions on issues and partnering with like-minded individuals whether or not it’s with regard to their scientific outcomes, whether or not it’s in regard to some actually cool improvements like Hospital at House, SNF at House, and issues like that. It truly is taking a look at these companions which have the identical imaginative and prescient, have the identical ardour in addition to attempt for that top stage of high quality.

Proctor: We’re working with a hospital that has developed a complete digital mannequin of care in a single explicit state, the one which they’re in. A few of my counterparts have been like, “I simply don’t know if we are able to actually use that.” I’m like, “I’m 100% positive we are able to. We’re getting a gathering with them as a result of I feel it’s cool. I feel digital is the place we’ve obtained to be going.”

Once they can say, “Look, that is the type of those who we’re partnering with. These are the sufferers we’re caring for out of our digital care heart, we are able to say nice as a result of we don’t have sufficient employees principally anyplace.” How can we take that digital? How can we do inside monitoring in a home with out really having to have a clinician there or with out having a nurse however you may ship a social employee issues like that.

Truthfully, with the ability to have these conversations and leaping off of what you’re doing, what you’re discovering in your space and taking them even when it doesn’t appear to be it’s going to use to your explicit sector is enormously useful.

Rhoades: Then give them info out to well being care.

Proctor: 100%.

Rhoades: I feel dwelling care may be very misunderstood. A number of the issues that we do within the dwelling and what might be executed. We have to all be higher about chatting with that as a result of they’re not conscious that you are able to do hospital at dwelling. You are able to do sure infusions at dwelling, wound care at dwelling, digital telemonitoring. There’s some actually cool stuff that folks aren’t conscious of.

Vanhoose: How do you all share that info internally together with your franchisees?

Rhoades: We do a ton of newsletters, info, conferences. Inside BrightStar, we’ve coaches that additionally assist help the workplace and issues like that so we’ve a number of ways in which that info will get out. City halls.

Proctor: We have now regional construction so the regional groups meet with the nationwide management group and it will get disseminated. Something will get disseminated that means, together with coverage modifications, issues like that. Additionally, most of our websites use the identical fundamental format for info that they’re offering. SNFs, for instance, on the standard of care that they supply, and in order that the identical fundamental type. It seems to be very comparable in the event you’re at a specific nursing dwelling in Miami versus Tampa. It’s going to look very comparable in order that they know what they’re taking a look at, they will share it internally themselves as properly. That’s been enormously useful. Standardizing issues has simply been unbelievable.

Vanhoose: Or retains it constant throughout the board as properly.

Proctor: Sure, precisely.

Rhoades: Folks know what they’re getting.

Vanhoose: That’s good. Lastly, let’s transfer on to tradition. Tradition can imply many issues to many various individuals from company tradition, what’s that definition out of your exterior prospects, your inside prospects? How are they affected by choices which might be made? When it comes to tradition, I feel all of us attempt to present the identical high-level high quality care and consistency throughout the board. How would you say, Josie, by way of BrightStar’s tradition, how has it modified, particularly within the mild of pandemics, the best way you used to do issues, and going ahead? How do you proceed to retain employees and develop?

Rhoades: There’s 5 big-ticket gadgets there. I feel tradition, we’re at some extent in well being care that we should be focusing extra on tradition, we should be specializing in our employees, ensuring that they’re joyful, ensuring that they belief individuals, I feel that’s one of many issues. Anytime that you just’re on our scientific group at Franchise Assist Heart, I feel it’s actually huge, in order that the tradition that they belief us, they usually can come to us. That tradition of security that they will come and say, “Hey, this occurred,” or, “I simply realized I wasn’t doing A, B, and C, what do I must do.”

I feel that one of many greatest issues is to ensure that individuals are comfy coming to us and really feel secure coming to us, it doesn’t matter what that’s. I feel that stems by way of a whole lot of that’s in the event that they belief their firm, in the event that they belief their scientific group with regard to nurses, which I work with most frequently. That flows all the way down to they’re happier, you could have higher retention. That constructive vitality flows into every particular person workplace that we’ve, every particular person location, so it truly is tradition begins from the highest and it’s in each facet.

Proctor: You even have higher high quality. Having that non-punitive tradition, particularly when anyone finds one thing improper is tremendous essential as a result of in any other case, you haven’t any concept what’s occurring, and also you received’t be capable to get correct information and also you’ll by no means know what’s going improper so as to have the ability to repair it. Folks need to do the proper factor. I consider, consider that. With the ability to give them the explanation behind why we’ve a specific coverage for us has been enormously useful as a result of in any other case, it’s simply, “Properly, company stated do that.”

You don’t need that there’s at all times a motive behind what we’re doing, and it’s normally to enhance their lives or the affected person’s lives. With the ability to clarify that and never being punitive after they miss it’s, I feel, tremendous key to bettering tradition.

Rhoades: That’s the way you repeatedly enhance high quality over time as you are taking even these remoted occasions and say, “Can this occur?” We’re going to be speaking about threat. Might this occur? Might this occur on an even bigger scale?

Proctor: Taking motion as shortly as attainable, no matter what the potential end result is. A very long time in the past, and I feel well being care has actually modified on this method. Once I first began, a whole lot of occasions, it was, “Okay, sweep it beneath the rug, it by no means occurred. So long as they don’t sue us, we’ll be completely high-quality.” Now, actually it’s, “Okay, repair it instantly. In the event that they sue us, we’ll no less than be capable to repair it.” That’s been tremendous essential for us will not be being the people who find themselves so afraid of the danger that you just’re not modern, that you just’re not doing the proper factor for sufferers.

Vanhoose: If it’s not documented, it wasn’t executed, right?

Proctor: That’s proper. That’s proper. Please doc.

Vanhoose: I feel one of many greatest issues was difficult tradition. Simply one thing that I’ve seen, in my expertise, was when anyone refers to dwelling well being, refers a affected person to dwelling well being, and also you’ll hear that it’s the affected person inhabitants. They don’t need anyone of their dwelling, or how do you overcome that, and the way do you, with that tradition, do you together with your staffing and affected person ratio? How do you all plan for that?

Rhoades: I feel whenever you discuss dwelling well being and residential care, one of many issues that I have a look at with regard, I do know COVID got here up or pandemic got here up with one in every of your questions, however I feel that’s one of many issues I’ve seen change with the pandemic is you now have prospects which might be customers. They’re taking a look at that, outcomes from completely different locations. They’re extra concerned, they’re taking a look at, “I don’t need to go to the hospital, I would like my care in my dwelling. I don’t need to ship my cherished one to a facility as a result of there’s threat concerned.

Most individuals are joyful at dwelling. Nearly all of individuals, I feel we heard someplace at present 98% or one thing, need to be within the dwelling. Mix that with our information, mix that with among the actually cool modern issues we’re doing, I feel it’s going to indicate a really completely different image of what individuals and sufferers consider dwelling care and residential well being.

Vanhoose: Proper, and I feel by way of the PI and the issues that the info that you just guys are gathering for PI, I feel it helps. It’s the general outcomes, which helps the standard metrics. Certainly one of you talked about I feel, Kate, is the one individual that complains, properly, guess what that impacts your age cap scores. It’s normally that one individual that fills it out, and it was mailed out to 300 individuals. Do you guys have some other issues that you just need to elaborate on in relation to information, tradition, or partnerships earlier than we conclude?

Rhoades: No, I imply, I feel it’s been very clear speaking to individuals at present that we have to do higher. The individuals on this room must do higher about outcomes, and the way can we have a look at these, how can we benchmark these, how can we get that info out, so it’s extra correct, extra usable, and other people might be held to greater requirements.

Proctor: Sure, and sharing it each internally and externally.

Rhoades: Externally for transparency.

Proctor: Not being afraid, individuals which may be competing with you in the identical space. Not everyone is a superb supplier, however there are sufficient of them which might be doing the proper issues, and to share greatest practices as a result of we actually do want higher greatest observe documentation.

Rhoades: Higher information, higher analysis.

Vanhoose: I feel we’ve heard some good general lectures at present. Simply take heed to the brainstorming concepts. I feel the one factor that all of us can agree on is that we set ourselves aside with the next customary of high quality and affected person security. I feel if we align with these objectives, that’s going to be our greatest end result for our sufferers which, by way of the company world, that’s going that can assist you general.

Proctor: Sure, precisely proper.

Vanhoose: We have now a query from the viewers, are you able to speak concerning the accreditation survey course of? How painful is it for a house care company when the shoppers could range?

Rhoades: I imply, I feel I’m an enormous fan of the Joint Fee. I feel the Joint Fee will get a extremely dangerous rep. Possibly it’s partially my relationship with him however it’s. Once more, we talked about punitive individuals asking our scientific leaders to return to me if there’s one thing. The Joint Fee is analogous, the Joint Fee is on the market to try this exact same factor, that they’re centered on schooling and bettering high quality general. Sure, surveys or surveys.

With the intention to be accredited by the Joint Fee, it’s displaying that you’re of a better high quality customary than anyone that’s not. There are going to be issues that you just do. It’s not that onerous.

Proctor: No. I feel the opposite factor is, particularly Joint Fee for us, no less than whenever you stroll right into a hospital and need to have a unit there or partnership there and even get a referral from there, you may say, “Look, you’re accredited by Joint Fee. I’m accredited by the Joint Fee.”

Rhoades: They perceive that.

Proctor: It’s a bit of the puzzle, you simply must type of skip over. Additionally, I feel once more, we even have each the Joint Fee and CHAP. I’ll say each of them are additionally actually inquisitive about bettering their very own processes.

Rhoades: The thought of being versatile, there’s unannounced surveys and also you’re not at all times going to bear in mind, however issues like within the pandemic flipping a digital survey.

Proctor: Or whenever you’re rolling out a brand new EMR being like, “Are you able to simply please not come to that week?”

Rhoades: Sure, blackout date. A few of these issues that I feel individuals don’t perceive among the flexibility as a result of most individuals know Joint Fee in a hospital sense, so it’s. I laughed about it as a result of the alert would go to each single unit and it might be just like the six or seven fits which might be strolling down the hospital and other people scatter. Not the identical in dwelling care. It’s a unique setting. It’s an setting of studying.

Vanhoose: I know you’ve been in dwelling care and in well being look after only a few days and this one query right here, after I say how painful, how have you ever observed the survey course of or the general stigma? Have you ever seen that change or a shift?

Rhoades: Sure, as a result of I feel extra individuals are specializing in high quality. Earlier than, it was seen on this dangerous mild, like, “Oh, we’ve to do that.” Persons are selecting to do that. That is one thing they select to do to show that they’re that top high quality. I feel if anyone who lives in Illinois has ever had a survey by the Illinois Division of Public Well being, Joint Fee is a breeze.

Proctor: Very true. It’s way more collaborative now than it was 10 years in the past, very a lot so, no less than with accrediting companies. Not all states are collaborative.

Rhoades: It’s. It’s a really collaborative course of and I feel that’s little by little beginning to change individuals’s thoughts about what that survey seems to be like.

Vanhoose: Yet another follow-up query to that. You talked about referral sources and hospitals and being the Joint Fee accredited. Now that you just guys are licensed and accredited, has that general impacted your referral quantity, you assume?

Rhoades: I completely assume so. Folks know that in well being care. Folks need to work with people who find themselves Joint Fee accredited.

The Joint Fee presents unbiased evaluation of high quality achievement in affected person care and security. To study extra go to