Joint Commission Research Articles

Abstract NS9: Nurse-Led Quality Improvement Initiative: Advancing Stroke Awareness in Communities Experiencing Racial and Ethnic Disparities

Background and Purpose: As a Joint Commission Comprehensive Stroke Center, the provision of community education is a priority goal of our program. The majority of our existing community education program takes place in locations where we receive requests to provide these sessions. Analysis of our Get With the Guidelines (GWTG) data reveals gaps in early arrival to the hospital and Emergency Medical Service (EMS) utilization among African American and Hispanic populations. Providing educational resources within these populations may help to close these gaps and foster trust in the healthcare system. The aim of this proposed nurse-led quality improvement project is to improve hospital arrival times of African American and Hispanic stroke patients living in zip codes where GWTG data have identified gaps, through provision of targeted community education. Methods: The top zip codes associated with our target outcomes for improvement will be identified using GWTG pre-data from 2022 and 2023. We will partner with our Community Outreach department. We will identify educational venues and stakeholders among African American and Hispanic populations in these zip codes. We will provide education tailored to our identified populations including early recognition of stroke signs and symptoms, activation of EMS, stroke risk factors, and opportunities for treatment. Post implementation, GWTG data will be reviewed for any changes. Results: Using GWTG data, arrival mode, last known well time, and symptom discovery time to Emergency Department arrival as it pertains to zip codes, race and ethnicity will be reviewed and analyzed. The target zip codes’ data will be compared pre- versus post-implementation of community education efforts. Discussion: Through community education and partnership with the Community Outreach department we hope to improve timeliness of arrival to hospital among disproportionately affected racial minorities in our community for early stroke evaluation and treatment consideration.

Infection Control Measure Performance in Long-Term Care Hospitals and Their Relationship to Joint Commission Accreditation

BackgroundThis study evaluated the relationship between Joint Commission accreditation and health care–associated infections (HAIs) in long-term care hospitals (LTCHs). MethodsThis observational study used Centers for Medicare & Medicaid Services (CMS) LTCH data for the period 2017 to June 2021. The standardized infection ratio (SIR) of three measures used by the Centers for Disease Control and Prevention's National Healthcare Safety Network were used as dependent variables in a random coefficient Poisson regression model (adjusting for CMS region, owner type, and bed size quartile): catheter-associated urinary tract infections (CAUTIs), Clostridioides difficile infections (CDIs), and central line–associated bloodstream infections (CLABSIs) for the periods 2017 to 2019 and July 1, 2020, to June 30, 2021. Data from January 1 to June 30, 2020, were excluded due to the COVID-19 pandemic. ResultsThe data set included 244 (73.3%) Joint Commission–accredited and 89 (26.7%) non–Joint Commission–accredited LTCHs. Compared to non–Joint Commission–accredited LTCHs, accredited LTCHs had significantly better (lower) SIRs for CLABSI and CAUTI measures, although no differences were observed for CDI SIRs. There were no significant differences in year trends for any of the HAI measures. For each year of the study period, a greater proportion of Joint Commission–accredited LTCHs performed significantly better than the national benchmark for all three measures (p = 0.04 for CAUTI, p = 0.02 for CDI, p = 0.01 for CLABSI). ConclusionAlthough this study was not designed to establish causality, positive associations were observed between Joint Commission accreditation and CLABSI and CAUTI measures, and Joint Commission–accredited LTCHs attained more consistent high performance over the four-year study period for all three measures. Influencing factors may include the focus of Joint Commission standards on infection control and prevention (ICP), including the hierarchical approach to selecting ICP–related standards as inputs into LTCH policy.

Abstract WP56: Neuroscience Nurse Navigator a New Compass in Continuation of Care Among Stroke Populations

Background and Purpose: Due to continued growth in our neurosciences program, of more than 1,400 discharged stroke patients per year, we saw a need for the creation of a Neuroscience Nurse Navigator (NNN) position, with initial efforts specifically focused in the stroke program. This role was developed as a means to meet and fulfill Joint Commission recommendations, along with the Comprehensive Stroke Certification (CSC) standards. Prior to the NNN role, compliance for attempted patient callbacks (a CSC requirement for those discharged home) was only 70%. Resources to support patient needs post-discharge were limited. Method: The process in creating this role began in 2020 and came to fruition in 2022. As a means to address patient call back compliance, those patients who have been identified as having a stroke, are visited as a point of introduction, also allowing time for unanswered questions. All stroke patients are called within a seven-day window, including those on our Neurosurgery service line. Patients are asked a series of 12 pre-set questions with calls varying from 6-10 minutes. To address the issue of post-discharge resources, the NNN aids in facilitating and arranging follow up appointments and is available to assist with patient questions prior to follow up appointments. The development of the stroke support group was initiated as well. Working with marketing and IT, the NNN created the Brain Matters stroke support group, which includes an informational postcard with QR code provided to stroke patients at time of discharge, and a separate email account. Patients can use this email to ask for a registration form for Brain Matters and allows the facilitator to communicate to the group as a whole. Results: Since implementing the NNN, attempted call-back rate among the 7-day calls have reached 100%, and completed call-backs (patient or family reached) increased from 70% to 85%. In relation to post-discharge resources, the creation of the Brain Matters stroke support group has been implemented and data is currently ongoing. Conclusion: The future plan is to further develop the NNN role as a necessary resource for all patients within the entire Neuroscience service line, including General Neurology, Epilepsy and Neurosurgery, as they navigate toward recovery.

Detection of tetracycline and ampicillin resistant E. coli and Salmonella species from hospital wastewater

Escherichia coli (E. coli) and Salmonella spp. were found in hospital wastewater. The highest (E = (6.2 ± 1.8) x 109; S = (4.3 ± 2.2) x 109) and lowest (E = (1.4 ± 1.2) x 109; S = (1.1 ± 1.8) x 109) Total Viable Count (TVC) were in Shaheed Suhrawardy Medical College Hospital (SSMCH) and National Institute of Ophthalmology Hospital (NIOH), respectively. The overall occurrence of E. coli and Salmonella spp. was 80% and 87%, respectively, with 100% occurrence in SSMCH and National Institute of Cardiovascular Diseases Hospital (NICVDH) for Salmonella spp. (p ≤ 0.036). Prevalence of E. coli was low (72%) in winter (November - February). Both types of bacteria were resistant to Tetracycline whereas and 97.5% of E coli were resistant to ampicillin. Gentamycin was more effective than other antibiotics. Rational use of antibiotics is suggested, and hospital management practice should be followed as defined by the Joint Commission International for Hospital Accreditation.
 Bang. vet. 2023. Vol. 40, No. 1 – 2, 16 – 24

Exploration of Norepinephrine Dose-Capping Practices: Report From an International, Interprofessional Survey of Critical Care Clinicians

Purpose: The Joint Commission standards for titrated infusions require specification of maximum rates of infusion. This practice has led to the development of protocolized maximum doses that can be overridden by provider order (“soft maximums”) and to dose caps that cannot be superseded (“hard maximums”). The purpose of this study was to determine the prevalence of and attitudes towards dose capping of norepinephrine. Methods: A 20-item cross-sectional survey assessing norepinephrine dose capping practices, perceptions of norepinephrine protocols, and respondent and practice site demographics was distributed electronically to the mailing list of an international medical podcast. Responses were stratified according to use of weight-based dosing (WBD) or non-WBD of norepinephrine. The primary objective was to characterize norepinephrine dosing practices including protocolized maximum doses and/or dose capping. Categorical and continuous variables were compared using the Chi-square test and Mann-Whitney U test, respectively, with P < .05 indicating statistical significance. Results: The survey was completed by 586 physicians, nurses, pharmacists, and advanced practice providers. WBD was used by 51% and non-WBD by 47%. A standardized titration protocol was reported by 65% and dose capping was reported by 19%. The protocolized maximum dose ranged from 20-400 mcg/min for respondents using non-WBD (median [interquartile range] 30 [30-50]) and ranged from .2-10 mcg/kg/min for respondents using WBD (1 [.5-3]). The dose cap was 50 (40-123) mcg/min with non-WBD and 2 (1-3) mcg/kg/min with WBD. Conclusions: An international, multi-professional survey of critical care and emergency medicine clinicians revealed wide variability in norepinephrine dosing practices including maximum doses allowed.

Proactive Risk Management using Healthcare Failure Mode Effect Analysis Tool to Improve Medication Management Process

Proactive risk management program is essential to maintain the quality and safety of patient care, treatment, and services within a healthcare system. According to the Joint Commission, hospitals need to adopt a proactive approach for risk management and develop risk mitigation strategies to reduce or eliminate the potentially harmful impact of possible risk. There are multiple tools that can be used for proactive analysis. Leaders of Evercare hospital Dhaka selected Healthcare FMEA tool to identify the potential failure modes in the current medication management process as it is one of the complex and high processes in healthcare settings. A multidisciplinary Healthcare FMEA team was formed comprising physician, nurse, pharmacist, quality, IT personnel and senior managements of EHD to conduct Healthcare FMEA. After completing Healthcare FMEA, twenty failure modes(n-20) and fifty-nine potential causes(n-59) of failure modes were detected in existing medication management process of EHD. The hazardous score was Two hundred &amp; seventeen (n-217). There were Twelve major failures modes with higher hazardous score. Healthcare FMEA team members decided to eliminate major failures and actions were taken to control these failures. The main objective of this study is to maintain the medication error of EHD within the target (2/1000 patient days) by implementing required strategies and redesigning existing medication management process. The limitation of this study was it is a time-consuming process, it only helps to identify the possibilities of fail; it does not eliminate them, additional efforts are required to develop corrective action. Pulse Vol.15, 2023 P: 28-33

Perception of Hospital Food Service Workers Regarding Patient Safety Culture and Patient Identification Practice

Implementing the 'Patient Identification' procedure during food distribution will ensure the right diet is served to the right patient. This study explored the perception of patient safety culture and its association with patient identification practices among hospital food service workers. We conducted a mixed method research in a Joint Commission International (JCI)-accredited hospital in Yogyakarta. Food service workers who received patient safety training and were responsible for distributing food in adult inpatient wards (n=76) participated in this study. Perception of patient safety culture was measured using a validated questionnaire and in-depth interview, whereas patient identification practice was observed directly using a checklist. Descriptive statistics and chi-square tests were employed. More than half (55.3%) of the subjects perceived overall patient safety culture well. However, 34.2% of the subjects performed substandard practice verifying the patient's identity (name, address, or medical record number) when delivering food. There was an insignificant association between the perception of patient safety and patient identification practice by food service workers (p0.05), as some considered that patient identification was more appropriate to be performed by other health professions instead of food service workers. Nevertheless, nearly all (98,68%) food service workers perceived their duty to match the patient's name with the label on the food tray as important.

Expression of GNAQ, BAP1, SF3B1, and EIF1AX Proteins in the Aqueous Humor of Eyes Affected by Uveal Melanoma.

The purpose of this study was to quantify specific aqueous humor (AH) proteins in eyes affected by posterior uveal melanoma (UM). Thirty-six eyes affected by primary UM were included. Tumor thickness and largest basal diameter were specific clinical characteristics. Tumors were staged with the American Joint Commission on Cancer Eighth Edition (AJCC) classification. During the brachytherapy (Iodine-125) surgical procedure, both the AH sample collection and the 25-gauge transscleral fine needle aspiration biopsy (FNAB) were performed. AH samples were analyzed by immunoprecipitation and SDS PAGE techniques to quantify GNAQ, BAP1, SF3B1, and EIF1AX proteins. Cytologic material underwent fluorescence in situ hybridization for chromosome 3. The AH of 36 healthy eyes was used as the control group. Cluster analysis of groups was also performed. Compared with the control group, significantly higher protein levels of: GNAQ (P = 0.02), BAP1 (P = 0.01), and SF3B1 (P = 0.02) were detected in eyes with UM. Cluster analysis of UM group revealed 2 clusters, one showing higher expression of GNAQ and BAP1 protein and one of EIF1AX protein. Moreover, the 2 clusters corresponded with the chromosome 3 status of UM. Specific and selected proteins may be detected in the AH of eyes affected by UM. These findings confirm the possibilities provided by AH analysis in UM.

Comparing Medication History Capture Rates In-Person Versus Hybrid: A Multisite Pilot Study.

Purpose: Medication history is the method many organizations use to adhere to The Joint Commission's (TJC) National Patient Safety Goal (NPSG) to communicate accurate patient medication information. Literature is sparse comparing the number of medication histories completed in-person versus virtually. Methods: This is a single system, multi-site, retrospective observational study. Patients included were admitted through the Emergency Department during October 2022. The primary aim of this study compared the percent capture rates of medication history between 2 hybrid sites to an in-person site within a health-system. Our secondary objective compared the differences in the 'medication history acuity score' (MHAS), defined as the total number of edits, additions, and deletions made during a medication history. Results: The medication history capture rate at the in-person site was 74% and at the hybrid sites were 91% and 80%. There were no differences in total medications on each medication history between in-person and hybrid (11 [5-16] vs 11 [6-16]; P = .252). There were no differences in changes made on medication histories between in-person and hybrid (4 [1-7] vs 3 [1-7]; P = .595). Conclusions: Our study demonstrates that medication history capture rates and MHAS are comparable in both in-person and hybrid environments. This similarity suggests the feasibility of implementing hybrid models for medication history services in diverse healthcare settings, potentially enhancing the capacity of health systems to meet TJC NPSG. These findings indicate that hybrid models could be an effective strategy for healthcare systems to optimize their medication history services, especially in settings with varied patient volumes and site specialties.

Registry-derived stage (RD-Stage) for capturing stage at diagnosis for pancreatic carcinoma in Australia.

Stage of pancreatic carcinoma at diagnosis is a strong prognostic indicator of morbidity and mortality, yet is poorly notified to population-based cancer registries ("cancer registries"). Registry-derived stage (RD-Stage) provides a method for cancer registries to use available data sources to compile and record stage in a consistent way. This project describes the development and validation of rules to capture RD-Stage (pancreatic carcinoma) and applies the rules to data currently captured in each Australian cancer registry. Rules for deriving RD-stage (pancreatic carcinoma) were developed using the American Joint Commission on Cancer (AJCC) Staging Manual 8th edition and endorsed by an Expert Working Group comprising specialists responsible for delivering care to patients diagnosed with pancreatic carcinoma, cancer registry epidemiologists and medical coders. Completeness of data fields required to calculate RD-Stage (pancreatic carcinoma) and an overall proportion of cases for whom RD stage could be assigned was assessed using data collected by each Australian cancer registry, for period 2018-2019. A validation study compared RD-Stage (pancreatic carcinoma) calculated by the Victorian Cancer Registry with clinical stage captured by the Upper Gastro-intestinal Cancer Registry (UGICR). RD-Stage (pancreatic carcinoma) could not be calculated in 4/8 (50%) of cancer registries; one did not collect the required data elements while three used a staging system not compatible with RD-Stage requirements. Of the four cancer registries able to calculate RD-Stage, baseline completeness ranged from 9% to 76%. Validation of RD-Stage (pancreatic carcinoma) with UGICR data indicated that there was insufficient data available in VCR to stage 174/457 (38%) cases and that stage was unknown in 189/457 (41%) cases in the UGICR. Yet, where it could be derived, there was very good concordance at stage level (I, II, III, IV) between the two datasets. (95.2% concordance], Kendall's coefficient = 0.92). There is a lack of standardisation of data elements and data sources available to cancer registries at a national level, resulting in poor capacity to currently capture RD-Stage (pancreatic carcinoma). RD-Stage provides an excellent tool to cancer registries to capture stage when data elements required to calculate it are available to cancer registries.

The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) compared with the Joint Commission International (JCI) and the American College of Radiology (ACR)

In this paper we compare the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) with the Joint Commission International (JCI) and the American College of Radiology (ACR) regarding accreditation of hospitals or radiology departments. CBAHI was established in 2005 by the Saudi Arabian Ministry of Health to improve the health care service to the public and to localize the protocols and the policies. CBAHI sets standards for healthcare facilities like hospitals, clinics, and laboratories according to CBAHI standards. The applying of these standards vary on the degree of enforcement of these standards in private or governmental sectors.

Prioritizing Equity in Antimicrobial Stewardship Efforts (EASE): a framework for infectious diseases clinicians.

Health equity gaps persist across minoritized groups due to systems of oppression affecting health-related social needs such as access to transportation, education and literacy, or food and housing security. Consequently, disparities in the prevalence of multidrug-resistant infections, infectious disease outcomes, and inappropriate antimicrobial use have been reported across minoritized populations. The Joint Commission and Centers for Medicare and Medicaid Services (CMS) have formally acknowledged the importance of integrating health equity-focused initiatives into existing hospital quality improvement (QI) programs. Here, we review documented disparities in antimicrobial stewardship and offer a framework, derived from components of existing health equity and QI tools, to guide clinicians in prioritizing equity in antimicrobial stewardship efforts (EASE).

Isolation and abuse: The intersection of Covid19 and domestic violence

Amid the global lockdowns, the surge in domestic violence cases has been one of the distressing consequences of the Covid19 pandemic [1]. Isolation, stress, and economic distress amongst other factors have all contributed to an increase in this form of abuse. Women have been subjected to discrimination and abuse for around 2700 years, and a clear example of such discrimination can be seen in the form of laws operating in 753 BCE that allowed the disciplining of wives [2]. The matter of domestic abuse started receiving recognition in the 1970s when it became a compulsion on all the certified hospitals by the Joint Commission on Accreditation of Health Care Organizations to refer patients of domestic abuse to authorities after treating them [3].

Interprofessional Education to Impact Professional Nursing Clinical Practice

Since the Joint Commission issued its roadmap for hospitals in 2010 outlining the need for interprofessional collaboration for safety, quality, and effectiveness in patient care, institutions have sought to improve the healthcare environment. While communication and teamwork have improved in recent years, the Joint Commission and the World Health Organization have continued to stress the importance of the key components of interprofessional collaboration: an understanding of other disciplines’ values/ethics and roles/responsibilities and the ability to communicate work as a team. Researchers have concluded the importance of introducing interprofessional education in pre-licensure settings to impact future healthcare professionals’ ability to collaborate with other disciplines in the workplace. Several nursing schools have implemented strategies for interprofessional education and are looking for new, innovative ways to simulate interprofessional collaboration for future practice.

Standardizing Medication Reconciliation in a Pediatric Emergency Department.

Medication errors are common during transitions of care, such as discharge from the emergency department (ED) or urgent care (UC). The Joint Commission has identified medication reconciliation as a key safety practice. Our aim was to increase the percentage of patients with completed medication reconciliation at discharge from our pediatric ED and 4 UCs from 25% to 75% in 12 months. Key stakeholders included ED and UC physicians and nurses, informatics, and quality management. The baseline process for medication reconciliation was mapped and modified to create a standard process for nurses and physicians. An Ishikawa diagram was created to assess potential failures. Electronic health record interventions included adapting an inpatient workflow and using a clinical decision support tool. Educational interventions included just-in-time training, physician education via division meeting presentations, video tutorials, and physician-specific and group feedback using funnel plots. The secondary process measure was the proportion of patients discharged from the ED and UCs with completed home medication nursing review. We used statistical process control to analyze changes in measures over time. In the UCs, home medication nursing review increased from 91% to 98% and medication reconciliation increased from 35% to 82% within 4 months. In the ED, home medication nursing review increased from 2% to 83% within 8 months and medication reconciliation increased from 26% to 64% within 18 months. We successfully increased the proportion of UC and ED discharged patients with completed medication reconciliation.

Policy and Process Considerations for the Updated Joint Commission Fluoroscopy Sentinel Event Definition

Policy and Process Considerations for the Updated Joint Commission Fluoroscopy Sentinel Event Definition

К вопросу об истории заседания Смешанной англикано-православной комиссии 1976 г. в Москве

The background and reasons for the 1976 meeting of the Anglican-Orthodox Mixed Commission in Moscow devoted to the development of relations between the Orthodox and Anglicans are analysed. The historical analysis of the development of relations between the Russian Orthodox Church (ROC) and the Church of England during the previous stages before the meeting of the Mixed Theological Commission within the framework of the development of church diplomacy is made. The conditions for the emergence of the Anglican-Orthodox Mixed Commission are examined. Examples of participation in previous meetings of representatives of the ROC are given. On the basis of source analysis the materials for the purpose of the article – to determine the place of the meeting of the Anglican-Orthodox Joint Commission in the development of the dialogue between the Russian Orthodox Church and the Church of England in the 1970s – are identified. The sources for the preparation of the materials of the article were review materials contained in the 1976 issues of the Journal of the Moscow Patriarchate (JMP), as well as materials from Russian archives. On the basis of the research of the available sources, the conditions of the commission meeting in 1976 were revealed. The list of participants from the Orthodox churches and representatives from the churches of the Anglican Commonwealth was determined. The main topic of the commission meeting was identified – discussion of the issues of interaction between the Orthodox and Anglicans. In addition, the results of the commission meeting – the agreed joint statement of the Orthodox and Anglicans on the results of the commission meeting – are analysed. Further steps in the development of relations between the ROC and the Church of England are indicated.

System justification theory as a foundation for understanding relations among toxic health care workplaces, bullying, and psychological safety.

Toxic work environments and bullying are rampant in health care organizations. The Joint Commission asserted that bullying is a threat to patient safety, and furthermore, it implied that bullying affects clinician psychological safety. However, after decades of trying to reduce bullying, it persists. The purpose of this study was to determine if system justification (SJ) theory can help explain the persistence of bullying in health care organizations. SJ theory posits that people are motivated to justify the systems with which they are embedded, even if those systems are dysfunctional or unfair. A cross-sectional survey of health care workers ( n = 302) was used to test a moderated mediation model to examine relations between instrumental work climate perceptions and psychological safety, as mediated by SJ and moderated by experiences of workplace bullying. Analysis revealed that SJ fully mediated negative relations between instrumental climate and psychological safety; because of SJ the instrumental climate no longer had a direct negative association with psychological safety. Furthermore, bullying was found to play a moderating role in the instrumental climate-SJ relationship. This study found some support for the role of SJ in perpetuating instrumental workplaces and workplace bullying in health care. Some scholars have proposed that a focus on disrupting workplace contexts that trigger SJ in workers could help break patterns of behavior that enable toxic work environments and bullying to persist.

Evolución de la percepción de la cultura de seguridad de los profesionales sanitarios en una urgencia pediátrica

Background and aimSafety culture (SC) is a fundamental tool for minimizing adverse events and improving safety and quality of care. Our objective, therefore was to analyze the evolution of the SC of healthcare professionals in a pediatric emergency department (PED) after the implementation of a risk management system for patient safety based on the UNE:EN:ISO 179003 Standard and the execution of new safe practices for Joint Commission International accreditation. At the same time describe the current strengths and weaknesses. MethodsQuasi-experimental, single-center study. All PED professionals participated in the study. An initial measurement of SC was performed through the Hospital Survey on Patient Safety Culture (HSOPS) questionnaire of the Agency for Healthcare Research and Quality adapted to Spanish in 2014. Pro-patient safety strategies were implemented between 2015 and 2022. A subsequent measurement was performed in 2022. ResultsThe response rate in 2014 was 55% and 78% in 2022. On both occasions the group with the highest participation was nurses with 35.1% and 34.8%, respectively.Five dimensions improved after the interventions: frequency of adverse events (25.2%, p<0.001), organizational learning (25%, p<0.001), feedback and communication about errors (22.3%, p<0.001), non-punitive response to errors (6.5%, p = 0.176), and management support (4%, p = 0.333). ConclusionsThe actions carried out had a positive influence on organizational learning and the frequency of adverse events reported and communication within the team. In contrast, the perception of SC did not increase.

Nothing About Patients Without Patients: More Than Just a Catchphrase!

Health care is sometimes called a "team sport," yet patients were traditionally not considered to be "on the team" in medicine. In 2001, the Institute of Medicine (now National Academy of Medicine) published its seminal book Crossing the Quality Chasm, in which patient-centered care was identified as 1 of 6 quality aims. Many organizations have since included patient-centered care as an important aspect of quality, including The Joint Commission, Centers for Medicare and Medicaid, and many large employers. In the past 10 years, the focus on patient-centered care has expanded in the Kaiser Permanente, Southern California region to include innovative ways for patients to collaborate with health care teams to codesign improvement efforts that are truly patient-centered. We will describe 3 important approaches that have greatly increased the patient-centeredness of our organization: individual patient approaches; adding patients onto health care teams; and effectively utilizing patient and family advisory councils. We will provide examples of how all health care organizations can better partner with their patients to improve their ability to provide higher quality, safer, more equitable, and affordable health care. The slogan "Nothing About Patients Without Patients" was an early rallying cry of the patient engagement movement. It conveyed the idea that as with everything else in our society, patients now expect to have a say in the design and implementation of their care. We show that this is not only possible, but also highly effective and even necessary to improving care.