Hamilton Niagara Haldimand Brant (HNHB) Performance Update Niagara - - PowerPoint PPT Presentation

1

Hamilton Niagara Haldimand Brant (HNHB)

Performance Update Niagara Health System & Other LHIN Hospitals

Presentation to the HNHB Local Health Integration Network (LHIN) Board of Directors

October 26, 2010

2

Agenda

Niagara Health System (NHS)

• Summary of 2009-10 performance on select performance metrics
• Contribution to Ministry-LHIN Performance Agreement (M-LPA)

performance targets

• Hospitals Performance Update September 2010
• Emergence Room (ER)- Alternate Level of Care (ALC)
• Wait Times – Select Services
• Quality – Select Metrics

NHS – Summary of 2009-10 Performance – Select Indicators

3

Service HNHB LHIN Target Niagara Health System LHIN Year End Performance (With Corridor) Q1 Q2 Q3 Q4 Cancer Surgery 50 70 53 55 61 58 Cataract Surgery 103 134 125 135 128 104 Hip Replacement 182 223 293 258 235 177 Knee Replacement 182 377 376 284 405 201 MRI 87 51 69 78 88 106 CT 33 38 44 45 44 48

• NHS wait times for cancer, cataract

and total joint replacement surgery were consistently above the LHIN target and showed little improvement during the year.

• NHS wait times for MRI & CT were

lower than those reported by the majority of other HNHB hospitals.

25.2% 22.7% 18.3% 13.8% 16.0% 16.0% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-093 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 P e r c e n t A L C Month

HNHB CCAC-Hospital ALC Scorecard Data

• NHS decreased its acute ALC rate in

2009-10 from 25% in April 2009 to 16% by March 2010, but remained higher than the LHIN target of 14%.

Source: Access to Care Cancer Care Ontario (ATC-CCO)

Pay for Results (P4R) 2009-10 Year End Summary

4

Indicator #1 Admitted ED LOS < 8hrs Non-Ad LOS < Indicator #2 mitted High Acuity ED 8hrs CTAS I,II, < 6 hrs CTAS III Non-Ad Indicator #3 mitted Low Acuity ED LOS < 4hrs MOHL Asses perform TC sed ance. Year 2 P4R Sites Baseline Year End Results % Improve- ment Baseline Year End Results % Improve- ment Baseline Year End Results % Improve- ment MOHLTC Weighted P4R Score Province (P4R sites) 28% 32% 4% 78% 80% 2% 78% 81% 2% HNHB LHIN (P4R sites) 28% 33% 5% 78% 80% 2% 75% 76% 1% Brant Community Healthcare System (BCHS) -General Site 37% 54% 17% 78% 78% 0% 63% 71% 8% 23

• St. Joseph's Hospital Hamilton

(SJHH) 27% 32% 5% 74% 84% 10% 70% 77% 7% 21 Hamilton Health Sciences Corp (HHSC) McMaster Site 31% 38% 6% 79% 83% 4% 78% 72%

• 6%

10 Joseph Brant Memorial 23% 28% 5% 82% 85% 3% 89% 89% 0% 8 HHSC General Site 27% 29% 2% 82% 83% 2% 74% 76% 3% 6 HHSC Juravinski Site 20% 23% 3% 83% 84% 0% 78% 77%

• 1%

4 Niagara Health System St. Catharines General Site (SCG) 27% 30% 2% 73% 72%

• 1%

70% 66%

• 4%

2 Green = Improvement met target of 10% 1) The MOHLTC assessed score was weighted whereby each Fiscal Quarter of 2009/10 was weighted higher than the previous quarter. The weighting was in a ratio of 1:3:6:9 . 2) A variable recovery rate was applied based on performance (ie score). Yellow = Above baseline and below 10% target Red = Performance same or below baseline

• NHS – St. Catharines General (SCG) site was one of two HNHB LHIN hospitals that

received ER P4R funding to reduce wait times in 2008-09 and 2009-10.

• Of the seven LHIN hospital sites that participated in ER P4R in 2009-10, NHS-SCG site

was amongst the worst performers in Ontario. As a result NHS will have a portion of there P4R funding recovered.

Source: MOHLTC–Yr2 Performance summary – weighted 25 May 10 final.

NHS’s Contribution to LHIN MLPA Targets

5

NHS’s performance can substantially impact the LHIN’s overall performance based on the percentage of the LHIN’s service volume they complete.

NHS Cataract Wait Time Trend

50 100 150 200 250 300 350 90th Percentile Wait Time (Days)

NIAGARA HEALTH SYSTEM 319314287205241240211206156159148153160165132139141135135121103117122129129143124104129128136141113134128123 Hamilton Niagara Haldimand Brant LHIN 16618514912013614813915210811311612713411510387 10610110710399 104110117114104 97 85 103100110107103101114109 Province 15215513212814114114114111812012012613212511810811911812011310310710711110599 93 96 108114116114103110110113 Priority 4 Access Target 182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182 Apr 07 May 07 Jun 07 Jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

SJHH Catarct Wait Time Trend

20 40 60 80 100 120 140 160 180 200 90th Percentile Wait Time (Days)

ST JOSEPH'S HEALTH CARE SYSTEM-HAMILTON 12412811499 12710591 83 80 10410010796 88 81 78 91 88 93 10810110310911597 92 85 81 91 92 85 81 89 87 98 86 Hamilton Niagara Haldimand Brant LHIN 166185149120136148139 15210811311612713411510387 106101107 10399 10411011711410497 85 103100110 107103101114109 Province 152155132128141141141 141118120120126132125118108119118120 11310310710711110599 93 96 108114116 114103110110113 Priority 4 Access Target 182182182182182182182 182182182182182182182182182182182182 182182182182182182182182182182182182 182182182182182 Apr 07 Ma y 07 Jun 07 Jul 07 Au g 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 Ma y 08 Jun 08 Jul 08 Au g 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 Ma y 09 Jun 09 Jul 09 Au g 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

In 2009-10 NHS and SJHH each completed 34% of the LHIN’s cataract volume; NHS reported wait times consistently higher than the LHIN target (103 days), SJHH ‘s wait time was consistently below the LHIN’s target.

Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010 Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010

NHS’s Contribution to LHIN M-LPA Targets

6

• In 2009-10 the LHIN was outside of its

performance corridor for total knee replacement surgery by 0.8 days.

• NHS completed 28% of the LHIN’s volumes,

the second highest to HHSC at 34%.

• In 2009-10 NHS reported monthly wait

times consistently higher than the LHIN target (182 days) ranging from 278-726 days. In 2009-10 other wait time services where NHS was a high volume contributor were:

• Total hip replacement surgery,

completing 24% of the LHIN volumes

• MRI services completing 30% of the

LHIN volumes

• CT services completing 38% of the LHIN

volumes.

Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010 Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010

NHS Total Knee Replacement Surgery Wait Time Trend

100 200 300 400 500 600 700 800 90th Percentile Wait Time (Days)

NIAGARA HEALTH SYSTEM 312 384 289 323 209 533 387 430 295 244 330 456 439 343 344 308 243 211 326 312 201 197 517 347 367 351 465 524 528 326 245 570 278 726 351 284 Hamilton Niagara Haldimand Brant LHIN 353 320 349 305 279 302 236 216 218 218 279 276 208 229 230 190 197 162 209 192 185 196 212 169 177 209 238 261 185 198 208 220 216 208 203 199 Province 337 321 302 294 281 300 285 258 253 244 257 244 224 248 223 202 231 205 204 200 189 194 184 176 189 195 187 178 175 178 178 186 177 176 172 180 Priority 4 Access Target 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 182 Apr 07 May 07 Jun 07 Jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

HHSC Total Knee Replacement Surgery Wait Time Trend

50 100 150 200 250 300 350 400 90th Percentile Wait Time (Days)

HAMILTON HEALTH SCIENCES CORP 356236334248351312223219207219235271195229196193203174172168186176212154178236310227176227211208216203174199 Hamilton Niagara Haldimand Brant LHIN 353320349305279302236216218218279276208229230190197162209192185196212169177209238261185198208220216208203199 Province 337321302294281300285258253244257244224248223202231205204200189194184176189195187178175178178186177176172180 Priority 4 Access Target 182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182182 Apr 07 May 07 Jun 07 Jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08 Aug 08 Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

2010-11 Performance Update – September 2010 Niagara Health System & HNHB LHIN Hospitals

7

8

ER & ALC 2010-11

• Pay for Results
• 90th percentile ER length of stay

(LOS)

• Percent ALC days

Year Three Pay-for-Results Performance

9

Proportion of Admitted patients treated within the LOS target of ≤ 8 hours

Year 3 P4R Sites Baseline Q1 Avg Jul-2010 Aug-2010 YTD % difference from baseline BCHS General site 47% 64% 58% 55% 61% 14% NHS Greater Niagara General 36% 35% 32% 31% 34%

• 2%

NHS SCG Site 30% 31% 29% 29% 30% 0% HHSC General site 29% 26% 26% 28% 26%

• 3%

HHSC McMaster site 36% 38% 35% 41% 38% 2% HHSC Juravinski site 24% 24% 27% 24% 25% 1% Joseph Brant Memorial (JBMH) 29% 28% 30% 28% 29% 0%

• St. Joseph's Hamilton

31% 34% 35% 30% 34% 3%

Proportion of Non-admitted complex patients (CTAS I-III) treated within their respective targets of ≤ 8 hours

Year 3 P4R Sites Baseline Q1 Avg Jul-2010 Aug-2010 YTD % difference from baseline BCHS General site 88% 87% 86% 84% 86%

• 2%

NHS SCG site 88% 87% 88% 85% 87%

• 1%

HHSC General site 91% 92% 92% 92% 92% 1% HHSC McMaster site 89% 91% 92% 92% 91% 2% HHSC Juravinski site 91% 93% 95% 92% 93% 2% Joseph Brant Memorial 91% 91% 89% 91% 91% 0% NHS SCG site 84% 84% 83% 83% 84% 0%

• St. Joseph's Hamilton

90% 90% 90% 90% 90% 0%

Proportion of Non-admitted low acuity (CTAS IV & V) patients treated within the LOS target of ≤ 4 hours

Year 3 P4R Sites Baseline Q1 Avg Jul-2010 Aug-2010 YTD % difference from baseline BCHS General site 69% 72% 69% 68% 71% 2% NHS SCG site 78% 81% 82% 74% 80% 2% HHSC General site 74% 83% 77% 76% 80% 6% HHSC McMaster site 74% 75% 78% 81% 77% 3% HHSV Juravinski site 76% 82% 80% 79% 81% 5% Joseph Brant Memorial 88% 90% 89% 92% 90% 2% NHS SCG site 67% 70% 59% 68% 67% 0%

• St. Joseph's Hamilton

75% 80% 82% 84% 81% 6%

= Maintained 90% = >1% above baseline =at baseline or below

Source: MOHLTC Emergency Reporting NACRS Initiative Oct 2010

• P4R Sites need to

achieve a combined 15% improvement across the three indicators to avoid recovery .

• As of August data:
• only NHS –SCG site

showed 0 (zero) improvement across the three indicators.

• Three LHIN hospitals

reported negative improvement on at least one indicator:

• NHS GNG site
• NHS SCG site
• HHSC General

site

• BCHS General

site.

MLPA Indicator 90th Percentile ER Length of Stay (LOS)

10 90th Percentile ER LOS for Admitted Patients This indicator is impacted by availability of inpatient beds & is the one metric of this indicator HNHB hospitals are challenged in meeting. Hospitals with higher wait times are:

• NHS- SCG, Welland & GNG

sites

• HHSC – General site
• JBMH

Site/Hospital Name P4R Sites Quarter 1 (Apr10-Jun10) July 10 August 10 Haldimand War Memorial Hospital No 2.7 2.6 2.8 Norfolk General Hospital No 6.0 5.9 6.2 West Lincoln Memorial Hospital No 9.2 7.6 8.8 NHS- Douglas Memorial No 3.5 3.5 3.3 NHS – Port Colborne No 3.4 3.5 3.4 NHS- Welland Hospital No 9.0 9.3 8.5 NHS - Greater Niagara General Yes 8.9 8.6 9.3 NHS- St. Catharines General Yes 9.2 9.6 9.6 HHS - McMaster Yes 7.9 7.4 7.5 HHS- Juravinski Hospital Yes 7.2 6.6 7.4 HHS- Hamilton General Yes 7.4 7.6 7.4 BCHS General Site Yes 8.6 9.0 9.3

• St. Joseph's Healthcare

Yes 7.9 8.1 8.2 Joseph Brant Memorial Hospital Yes 7.5 8.2 7.6

HNHB LHIN Total = 7.5 hours 7.8 7.9 8.0

90th Percentile ER LOS for Non-Admitted High Acuity Patients Hospitals with higher wait times (9 hours or over) are:

• NHS- SCG, Welland & GNG sites
• BCHS

Site/Hospital Name P4R Sites *March 31 2011 Target (hrs) Quarter 1 (Apr10- Jun10) July 10 August 10 Haldimand War Memorial Hospital No 5.7 5.1 4.4 7.6 Norfolk General Hospital No 18.1 18.9 12.1 20.2 West Lincoln Memorial Hospital No 25.7 26.9 21.8 23.7 NHS- Douglas Memorial No 23.9 11.9 10.5 10.8 NHS – Welland Sitr No 39.0 45.5 53.3 42.8 NHS - Greater General Yes 39.2 50.6 65.3 61.4 NHS- St. Catharines General Yes 28.7 45.2 47.1 42.1 HHS - McMaster Yes 22.5 22.8 25.4 24.9 HHS - Jurvanski Yes 22.7 28.3 27.6 28.3 HHS- Hamilton General Yes 23.9 33.9 31.4 35.9 BCHS – General Site Yes 23.3 19.4 25.3 27.4

• St. Joseph’s Healthcare

Yes 25.2 21.7 24.9 27.5 Joseph Brant Memorial Hospital Yes 44.5 69.0 77.0 70.0 HNHB LHIN Total 28.3 35.4 40.5 38.0

Source: MOHLTC Emergency Reporting NACRS Initiative Oct 2010 * LHIN identified target each site needed to reach

MLPA Indicator 90th Percentile ER Length of Stay

11 90th Percentile ER LOS for Non- admitted Low Acuity Patients

Site/Hospital Name = P4R Sites Quarter 1 (Apr10-Jun10) July 10 August 10 Haldimand War Memorial Hospital No 1.7 1.5 1.8 Norfolk General Hospital No 4.5 4.2 4.6 West Lincoln Memorial Hospital No 5.0 5.3 5.3 NHS- Douglas Memorial No 2.1 2.1 2.3 NHS – Port Colborne No 2.4 2.8 2.5 NHS- Welland Hospital No 6.9 6.5 6.0 NHS - Greater Niagara General Yes 5.3 5.0 6.1 NHS- St. Catharines General Yes 6.3 7.3 7.0 HHS - McMaster Yes 6.0 5.7 5.5 HHS- Juravinski Hospital Yes 5.0 5.4 5.4 HHS- Hamilton General Yes 5.0 5.4 5.5 BCHS General site Yes 6.3 6.9 6.7

• St. Joseph's Healthcare

Yes 5.2 5.1 4.8 Joseph Brant Memorial Hospital Yes 4.1 4.2 3.6 HNHB LHIN Total = 4.5 hours 4.8 4.8 4.8

Source: MOHLTC Emergency Reporting NACRS Initiative Oct 2010

Hospitals with higher wait times (6 hours) are:

• NHS- SCG, Welland & GNG

sites

• BCHS

HNHB LHIN Acute ALC Rate

12

HNHB CCAC-Hospital ALC Scorecard Data

Month Apr‐10 May‐10 Jun‐10 Jul‐10 Aug‐10 LHIN ‐ 2009'10 22.5% 23.1% 21.8% 20.6% 18.5% Target ‐ 2009'10 14.0% 14.0% 14.0% 14.0% 14.0% Target ‐ 2010‐11 11.0% 11.0% 11.0% 11.0% 11.0% LHIN ‐2010‐11 13.2% 13.3% 13.3% 15.4% 15.6% BCHS ‐ 2010'11 8.4% 8.2% 7.2% 9.3% 9.9% HHS ‐2010'11 10.5% 10.3% 9.9% 11.7% 12.8% NHS ‐2010'11 14.3% 14.7% 16.8% 20.5% 18.5%

• St. Joseph's ‐2010'11

16.9% 17.5% 16.3% 19.3% 19.2% JBMH ‐ 2010'11 20.4% 22.4% 22.5% 20.1% 21.4% HWMH ‐ 2010'11 11.4% 14.3% 14.4% 17.4% 17.0% NGH ‐ 2010'11 7.2% 7.6% 4.4% 2.2% 5.1% WHGH ‐ 2010'11 14.7% 12.4% 18.9% 18.5% 24.4% WLMH ‐ 2010'11 23.5% 6.4% 7.4% 14.1% 15.2%

NHS like many other LHIN hospitals is seeing an increasing trend in their ALC rate

• ver the summer,

except for JBMH.

13

Surgical & Diagnostic 2010-11 Wait Times

90th Percentile Wait Time for:

• Cancer, cataract, total joint

(knee & hip) replacement surgery and Diagnostic MR

Cancer & Cataract Surgery 90th Percentile Wait Times

14

Cancer Surgery TARGET Q1 (Apr-Jun) July August Sept Provincial 59 56 65 66 HNHB 58 62 55 65 57 HHSC 58 45 47 65 55 JBMH 58 70 67 78 71 NHS 58 70 55 76 44 SJHH 58 72 63 59 73 BCHS 58 66 46 65 60 Cataract TARGET Q1 (Apr-Jun) July August Sept Provincial 117 113 127 134 HNHB LHIN 104 115 102 132 139 JBMH 104 113 113 134 148 NHS 104 136 100 164 143 NGH 104 75 96 106 106 SJHH 104 105 105 132 136 BCHS 104 55 48 62 83

• LHIN wait times are relatively constant with

higher wait times at JBMH and SJHH.

• NHS wait times improved in Second

Quarter (Q2), except for a spike in August.

• Cancer wait times are driven by wait times

for specific cancer surgery.

• LHIN wait times for cataract surgery are

increasing (consistent with provincial trend).

• Four hospitals are reporting wait times

higher than the LHIN target, two of these hospitals together complete the majority of the LHINs volumes.

Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010

Total Knee & Hip Replacement Surgery 90th Percentile Wait Times

15

Knee Replacement TARGET Q1 (Apr-Jun) July August Sept Provincial 184 202 207 197 HNHB LHIN 182 207 213 228 217 HHSC 182 209 251 234 210 JBMH 182 198 132 204 216 NHS 182 235 181 284 219 SJHH 182 187 196 289 239 BCHS 182 89 62 59 64 Hip Replacement TARGET Q1 (Apr-Jun) July August Sept Provincial 170 176 162 188 HNHB LHIN 177 190 155 167 194 HHSC 177 177 180 182 217 JBMH 177 224 76 167 156 NHS 177 225 95 176 148 SJHH 177 135 244 147 221 BCHS 177 110 55 59 55

• LHIN wait times for total hip replacement

surgery increased at First Quarter (Q1).

• It is expected that the LHIN’s Q2 wait time will

be lower that Q1, depending on the impact of the high wait time in September.

• NHS’s wait times improved over 2009-10;

higher wait times at HHSC & SJHH are impacting the LHIN’s performance.

• LHIN wait times for total knee replacement

surgery are increasing.

• NHS wait times are improving over

2009-10, however wait times at three other LHIN hospitals are also increasing over the summer months.

Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010

MRI & CT 90th Percentile Wait Times

16

MRI TARGET Q1 (Apr-Jun) July August Sept Provincial 114 119 122 125 HNHB LHIN 95 112 121 128 116 HHSC 95 111 105 118 119 JBMH 95 102 103 113 117 NHS 95 78 84 87 88 SJHH 95 133 155 171 169 BCHS 95 111 124 134 102 CT TARGET Q1 (Apr-Jun) July August Sept Provincial 35 35 34 33 HNHB LHIN 43 42 44 46 45 HHSC 43 44 47 53 50 JBMH 43 84 65 76 67 NHS 43 39 42 44 39 SJHH 43 39 36 35 31 BCHS 43 41 46 48 48 NGH 43 25 23 29 21

• LHIN wait times for MRI services are

increasing, this is consistent with the provincial trend.

• NHS wait times have remained stable and

below the LHIN target.

• Hospitals are reporting increased demand

driving the wait times.

• LHIN wait times for CT while relatively

stable, continue to be above the LHIN target and province’s 90th percentile wait time.

• For Q2, three LHIN hospitals are reporting

higher wait times that will likely impact the LHIN meeting its target;

• HHSC
• JBMH
• BCHS

Source: ATC-CCO Adult Surgery and DI Hospital Trend Report Monthly March 2010

NHS All Sites – Publically Reported Patient Safety Indicators

17

Patient Safety Indicator 2009-10 April- June 2010 Provincial Average April – June 2010 Jul 2010 Aug 2010 Sept 2010 July- Sept 2010 MRSA Bacteraemia Infection rate per 1,000 patient days 0.02 0.02 0.05 0.05 0.00 0.00 0.02 VRE Bacteraemia Infection rate per 1,000 patient days 0.01 0.00 0.00 0.00 0.00 0.00 0.00 Surgical Site Infection Prevention - Timely Antibiotic Administration for Total Joint Replacement 70.46% 96.06% 90.79% 85.29% 92.16% 96% 91.49% Surgical Checklist Compliance n/a 92.04% 100% 100% 100% 100% 100% CLI-BSI Rate per 1,000 Central Line days 0.00 0.94 0.00 0.00 0.00 0.00 0.00 VAP Rate per 1,000 Mechanically Ventilated days 0.53 2.2 0.00 0.00 0.00 0.00 0.00 CDAD Incident Rate per 1,000 Patient days 0.33 0.28 0.51 0.47 0.52 0.49 0.49 HSMR – ratio HSMR – Confidence Interval 105 98-112 100 98 85-112 Key – Based on Last Quarter Provincial Average Better than Q1 Provincial Average Same as Q1 Provincial Average Worse than Q1 Provincial Average

Source: NHS Performance Report Oct 2010

• NHS is implementing

action plans to improve performance

• n public reported

quality indicators.

18

Questions?