Shelley Johnson

A Case Study of Organizational

Risk on Hospital-Acquired
Infections
O
N ANY GIVEN DAY, 1 of every CDC’s National Healthcare Safety
EXECUTIVE SUMMARY 25 patients hospitalized in Network (HNSH) benchmarks.
Hospital-acquired infections
the United States will The estimated additional cost of
(HAIs) pose a significant threat have a hospital-acquired care related to CAUTIs, CLABSIs,
to health care and healthcare
organizations.
infection (HAI) (Centers for and C. diff in the organization
Disease Control and Prevention totaled $1,384,000 in 2016, down
HAIs cause patient safety, ethi- [CDC], 2018a). These infections slightly from $1,440,352 in 2015
cal, regulatory, financial, and
legal risk.
are a patient safety risk and add to (see Table 1). The organization’s
the cost of health care. They are goal was to decrease each of these
The HAI workgroup at one also mostly preventable. While HAIs by at least 20% in 1 year by
organization is leading improve-
ment efforts that require every
this number of HAIs has been engaging an interprofessional

individual in the organization to

declining since 2009, there is still workgroup of frontline staff mem-

be engaged in the improvement

work to be done to achieve a goal bers to focus on improving

efforts.
of eliminating HAIs (CDC, 2018a; processes and practices related to

Understanding root causes, fol-

Institute for Healthcare Improve- HAIs. This article describes the

lowing the Institute for

ment [IHI], 2018a). efforts employed by the work-

Healthcare Improvement model

for improvement to deploy inter-
ventions, communicating HAI
stories to the frontline, and
implementing staff improvement
ideas have all proven effective
in addressing HAIs.
The community, patients, and
the organization’s reputation as
a quality provider of health care
depend on these continuous
improvement efforts.
The current rate of HAIs in a
community hospital and health-
care organization in Northern
California places it at high risk for
patient safety, ethical, regulatory,
financial, and legal exposure.
HAIs causing the most concern are
catheter-associated urinary tract
infections (CAUTIs), central line-
associated bloodstream infections
(CLABSIs), and Clostridium diffi-
cile (C. diff) infections. Numbers
and rates of HAIs were the same or
increased in 2016 compared to
2015. These HAIs are above the
group the first year.
Literature Review
C. difficile infections. Hospital-
acquired C. diff infections are a per-
sistent problem for patients and
healthcare providers. C. diff is a
spore bacterium that can survive
for long periods of time on sur-
faces. Patients who have received
antibiotics are at increased risk for
developing a C. diff infection.
Normal flora in the intestinal tract
that helps prevent infections is
depleted with antibiotic treatment.

SHELLEY JOHNSON, MHA, BSN, RN, CENP, CNL, is Director, Critical Care Services,
NorthBay Healthcare, Fairfield, CA.

128 NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3

 Table 1.
Current CLABSI, CAUTI, and C. diff

2016 Estimated
Additional Cost of
HAI 2015 2016 Care Related to HAIs
CLABSI number 8 9 $144,000
CLABSI rate (number of CLABSI infections/1,000 line days) 1.15 1.15
CLABSI benchmark (NHSN mean) 0.9 0.9
CAUTI number 7 15 $30,000
CAUTI rate (number of CAUTI infections/1,000 urinary catheter days 0.89 1.35
CAUTI benchmark (NHSN mean) 1.25 1.3
C. diff number 66 61 $1,200,000
C. diff rate/10,000 patient days 15.9 12.77
C. diff benchmark (NHSN per 10,000 patient days) 7.4 7.4
Total number of all three HAIs 81 85
Total estimated cost of all three HAIs $1,374,000
CAUTI = catheter-associated urinary tract infection, CLABSI = central line associated bloostream infection, C. diff =
Clostridium difficile, HAI = hospital-acquired infection, NHSN = National Healthcare Safety Network

The primary ways to prevent hos-
pital acquired C. diff infections are
by thorough caregiver handwash-
ing between patients, limiting
antibiotic use, isolating patients
with known C. diff infection, effec-
tive cleaning of patient rooms
using a spore killing cleaner, and
preventing cross-contamination by
appropriately cleaning equipment
between patients and wearing per-
sonal protective equipment (PPE)
(CDC, 2012; Dubberke et al., 2014).
C. diff contributes to increased
morbidity and mortality and
accounts for increased costs of
care. C. diff infection costs for first-
time and recurrent infections aver-
age between $13,168 and $28,218
(Shah et al., 2016). Because the C.
diff spore can live for months on
surfaces, it is easily spread from
person to person via hands that
have touched contaminated sur-
faces (CDC, 2018a).
C. diff is the most common
hospital-acquired pathogen and
the leading cause of death associ-
ated with gastroenteritis (Shah et
al., 2016). In 2011, there were over
half million C. diff infections in
the United States alone. Of those
half million infections, 24% were
classified as hospital-acquired
while 66% were classified as
healthcare-associated. In 2007, it
was estimated that C. diff caused
14,000 deaths and it is anticipated
that rates of C. diff will continue to
rise. This increase may be in part
because of more sensitive testing,
but also because the infection is
highly transmittable (Lessa et al.,
2015).
Catheter-associated blood
stream infections. Central lines are
catheters that end in a great vessel
such as the aorta, vena cava, sub-
clavian, or femoral veins and are
used for blood withdrawal, hemo-
dynamic monitoring, or infusions
(CDC, 2018b). Nearly 50% of all
patients in intensive care have a
central line, equating to 82,000
central lines used annually in U.S.
hospitals. There are 28,000 deaths
related to central-line bloodstream
infections each year. CLABSIs cost
between $3,700 and $29,000 in
additional health care per patient
and can add up to 7 additional
days to a hospital stay. These
infections are expensive, add to
morbidity and mortality, and are
preventable (IHI, 2012; Sacks et al.,
2014).
Sacks and colleagues (2014)
compared the CLABSI infection
rate 1 year pre and 6 months post-
intervention with the IHI CLABSI
prevention bundle in a surgical
intensive care unit. A same-size
medical intensive care unit was the
control unit. Study results showed
a 68% decrease in the CLABSI rate
on the intervention unit, 12
CLABSIs were prevented, and
annual savings in unnecessary
patient care costs of $198,600. The
CLABSI prevention bundle in-
cludes hand hygiene, barrier pre-
cautions on insertion, chlorhexi-
dine skin preparation, site selection
such as avoiding the femoral area,
and daily review of line necessity
(IHI, 2012).
Valencia and co-authors (2016)
conducted a worldwide survey in
intensive care units to assess prac-
tices related to the CLABSI preven-
tion bundle. They categorized
respondents by country and sorted
the nations into low income, mid-
dle income, and high income. No
low-income countries, 14 middle-
income countries, and 27 top-

NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3 129

 Table 2.
CDC Guidelines for Appropriate Indwelling Urinary Catheter Use
Appropriate Reasons for
Indwelling Urinary Catheters
• Urinary retention or a bladder
obstruction
• Intensive care unit patients who
need accurate urinary output
measurement
• Patients with healing sacral or per-
ineal wounds and who are inconti-
nent
• Prolonged patient immobility typi-
cally related to a traumatic event
• End-of-life care
SOURCE: CDC, 2018c
income countries responded. Their
findings concluded 80% or more of
the respondents in both middle
and high-income countries have
access to CLABSI prevention
guidelines, but only 23% of mid-
dle-income country respondents
and 62% of high-income country
respondents reported compliance
with the guidelines. While most
respondents indicated the need to
understand their CLABSI rates, few
could report their current rate
(Valencia et al., 2016).
Catheter-associated urinary
tract infections. Urinary tract
infections (UTIs) are the most fre-
quent HAI. Forty percent of all
HAIs are attributed to UTIs, while
80% of those are associated with
an indwelling urinary catheter
(IUC). The healthcare-associated
expenses related to a CAUTI or
bacteremia related to the UTI con-
tribute an average additional cost
of $2,000 per case (IHI, 2018b).
Because of their frequency and
associated costs, reducing CAUTIs
is a priority. The CDC has specific
indications of when an IUC
should be used (see Table 2).
Despite the CDC indications, 21%
of patients in hospitals have an
IUC and half of them have no
identified reason for insertion or
continuation (IHI, 2018b).
Patients with IUCs have a high
130
Appropriate Reasons for
Perioperative Indwelling
Urinary Catheters
• Urologic or genitourinary proce-
dures
• Planned for the patient to receive a
large volume of fluid or diuretics
• Intraoperative monitoring or urinary
output
risk of UTIs for many reasons. The
urine from an IUC is collected into
a bag. The bag is often a harbor for
bacteria growth. Patients can
become infected if there is a back-
flow of urine from the bag, if there
is a break in the closed system of
the IUC, or from biofilm that exists
on the catheter itself. Lack of care-
giver handwashing or contaminat-
ed supplies when inserting or
maintaining the IUC also adds risk
for infection (Boev & Kiss, 2017).
Often, IUCs are not removed when
the indication for use expires,
which leads to unnecessarily
extended dwell times. The dwell
time of an IUC can contribute to
infection risk (Clayton, 2017; IHI,
2018).
Several recent studies and
quality improvement projects have
shown improvement in CAUTI
rates. These studies focus on fol-
lowing the CDC and IHI guidelines
regarding IUC reason for insertion,
aseptic insertion practices, use and
maintenance practices, and timely
removal of IUCs. Healthcare pro-
vider knowledge of unit or organi-
zation CAUTI rates and catheter
days also contributed to decreasing
CAUTIs. Implementing direct ob-
servation of IUC insertions also
yielded decreased CAUTIs. Dili-
gently following established evi-
dence to prevent CAUTIs is effec-
NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3
tive, and organizations can improve
compliance with the guidelines to
avoid CAUTIs (Galiczewski &
Shurpin, 2017; Parker et al., 2017;
Taha et al., 2017).
Organizational Risk Assessment
HAIs increase length of stay,
mortality, and cost of care (Sacks et
al., 2014). These avoidable costs
with potential legal liability may
compromise the organization’s
financial health. High HAI rates
can threaten an organization’s rep-
utation for providing safe, high-
quality care. The literature suggests
full implementation and consistent
use of prevention guidelines is not
widespread. Healthcare organiza-
tions must provide a safe environ-
ment for patients to receive care,
and therefore a commitment to
implement evidence-based HAI
prevention strategies. Using pub-
lished evidence-based guidelines
and care bundles will significantly
decrease HAIs.
A healthcare organization in
Northern California is diligently
working to decrease HAIs and the
organizational risks associated
with them. The organization’s mis-
sion is to provide the highest qual-
ity care to the community it serves.
The organization was founded by a
grassroots community effort in the
mid-20th century. With the uncer-
tainty of healthcare reform and
transparent governmental public
reporting, there is added health-
care provider focus on community
trust, high-quality care, smooth
care transitions, and high financial
performance.
In 2017, the Joint Commission
changed its accreditation evalua-
tion model to the Survey Analysis
for Evaluating Risk (SAFER) matrix.
The SAFER matrix provides sur-
veyors the opportunity to score
identified issues based on the like-
lihood of causing harm to patients,
staff, or visitors and the pervasive-
ness of the problem (The Joint
Commission, 2016). Improvement
in HAIs must be addressed to aid in
a successful survey and continued
accreditation.
 Table 3.
HAI Alignment to COSO Enterprise Risk Management Model
COSO Category Definition
Primary Objectives
Strategic High-level goals aligned with and support
the institution’s mission
Operations High-level goals aligned with and support
the institution’s mission
Reporting Internal or external reporting of risks/poten-
tial risks
Compliance Adherence to laws and regulations
Interrelated Components
Internal environment The tone of an organization and how risk is
viewed and addressed
Objective setting The process an organization uses to set its
goals and objectives; Objectives must exist
before management can identify potential
events affecting their achievement.
Event identification Identification of internal and external events
that impact the achievement of goals
Risk assessment Analyze risks for impact so the best course
of action to address the risk can be taken.
Risk response Selection of risk responses including: avoid-
ing, accepting, reducing, or sharing
Control activities Policies and procedures support risk
responses are carried out effectively.
Information and communi- Relevant information is identified, captured,
cation and communicated so people can fulfil their
responsibilities.
Monitoring Risk management components are moni-
tored and modifications made as needed.
NOTE: Adapted from COSO, 2004
CAUTI = catheter-associated urinary tract infection, CLABSI = central line associated bloostream infection, C. diff =
Clostridium difficile, CMS = Centers for Medicare & Medicaid Services, HAI = hospital-acquired infection
NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3
HAI Risk Alignment
Aligns with all three components of the
strategic plan of enhancing trust, seamless
care, and maintaining independence.
Improvement of HAIs aligns with mission of
organization and management goals for
2017.
Public reporting: 22% of the CMS star rating
system is attributed to safety. CAUTIs,
CLABSIs, and C. diff are three of eight com-
ponents that make up the safety category.
Potential self-reporting to regulatory bodies
based on severity of HAI/patient event
HAIs integrated into weekly managerial
report of risk events sets it as a priority focus
for organization.
HAI improvement set as managerial objective
for 2017. This objective has also been cas-
caded via the performance evaluation
process to frontline employees.
Infection prevention notifies unit leaders of
event as close to real time as possible.
Infection prevention and unit leaders perform
root cause analysis of each event to evaluat-
ed risks and opportunities related to event.
Reducing is the risk response for HAIs.
Individual event responses will be determined
with each root cause analysis.
HAI team is establishing processes to pre-
vent HAIs, but also to respond to HAI events
for root cause analysis and response.
HAI team is establishing visual management
quality boards for HAI outcomes and “real
time” fallout review and discussion. This infor-
mation will roll up to the HAI steering commit-
tee and organization quality committee.
HAI outcomes monitored closely. Process
and practice improvements monitored and
adjusted using Plan-Do-Study-Act method as
the data and monitoring warrant.
131
 Figure 1.
Sample Case Review of a Hospital-Acquired CAUTI Incident

Situation
There was a catheter-associated urinary tract infection (CAUTI) on 4/1/17. This is our 4th CAUTI in 2017.

Background
Patient is an 84-year-old male with history of BPH, dementia, CVA, and UTI on admission. Admitted through the ED to
hospital on 3/14/17.
3/14/17: Patient fell at home and fractured his hip. Foley catheter placed in ED. Patient admitted to med/surg. No initial
Foley catheter order entered in EHR (order on paper). Patient’s UTI identified as ESBL E. coli on admission and was
placed on isolation and 7-day treatment begun.
3/15/17: Patient to OR then to ICU post op. Order to d/c Foley on POD 2.
3/16/17: Foley was not removed per physician order. Chlorhexidine (CHG) bathing not completed on this day.
3/17/17: Patient cleared for weight bearing as tolerated with PT.
3/19/17: Patient transferred to med/surg.
3/23/17: RN completed the d/c Foley order from 3/15 in chart check, but Foley remained in place. During hospital course,
patient’s mobility was max assist, patient’s health status declined, and there was consideration of comfort care.
4/1/17: Patient febrile with blood and clots in urine. Catheter removed. Blood and urine cultures ordered and collected.
Both resulted positive for Pseudomonas. Patient made comfort care.

Assessment
• Dwell time for Foley catheter placed on admission was 19 days. This is a really long time.
• There was no electronic order for a Foley catheter on admission.
• No electronic insertion order for a Foley catheter defeated all the safeguards imbedded in EHR to prevent a CAUTI.
The major safeguard is a daily justification alert (with reason) for providers to document continued Foley use.

Recommendations
• Ensure every indwelling Foley has an insertion order in the EHR.
• Inquire about continued Foley necessity every day.
• Review line necessity daily. Providers to complete justification alert with proper reason for continuation documented.
• CHG bathing to be completed daily on every ICU patient and every med/surg patient with a Foley or central line.
• Complete and document Foley care daily and prn.
• Ensure Foley secured properly with securement device, tube not kinked, Foley bag in a dependent position: below
level of bladder but not on the ground.

Risk Mitigation
The organization strives for
zero HAIs; however, because hos-
pitalized patients typically have
compromised immune systems
and hospitals treat infectious
patients, zero HAIs is difficult to
realize. The organization evaluat-
ed its risk appetite related to HAIs.
The risk tolerance should mini-
mally be below the NHSN nation-
al benchmark for each specific
HAI (Hopkin, 2014a).
Risk mitigation tools. The
Committee of Sponsoring Organi-
zations of the Treadway Commission
(COSO) Enterprise Risk Manage-
ment framework is a tool to evalu-
ate risk and develop strategies to
mitigate risk comprehensively. The
COSO model assists with assessing
various risk components individu-
ally, and how they integrate with
each other. The model supports
typical management components
of an organization (COSO, 2004)
(see Table 3).
The 4Ts of hazard manage-
ment (tolerate, treat, transfer, ter-
minate) are helpful in considering
how to address risk. The best
option for HAIs is to manage the
risk to prevent the occurrence.
Decreasing the exposure and
impact of HAIs will manage the
risk. Treat is the appropriate man-
agement strategy because HAIs are
likely to happen, but they have a
mid-range impact to the organiza-
tion’s overall risk considerations
(Hopkin, 2014b). Tolerating, trans-
ferring, or terminating risk would
not apply as options in hazard
management strategies for HAIs.
Risk mitigation actions. The
organization developed a frontline
staff workgroup to address the high
number of HAIs and evaluate HAI
outcomes as they relate to process-
es and practices. Physicians, nurs-
es, pharmacists, laboratory techni-
cians, clinical nurse specialists,
clinical nurse leaders, infection
prevention (IP) nurses, and envi-
ronmental services are representa-
tives on the workgroup. The HAI
workgroup is evaluating the extent
evidence-based practice standards
are integrated into the organiza-
tion’s policies. They also assess
work practices related to each HAI
to guide improvement activities.
The HAI workgroup reports events
and outcomes to the HAI steering
committee that reports to the orga-
nization’s quality committee. The
accountability to the workgroup’s
actions and the committees pro-
vide resources should the team

132 NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3

 Table 4.
HAI Workgroup Interventions
Issue HAI Team Interventions
C. diff
Collection audit tool for frontline providers and staff to be completed before sending any
Stool collection criteria
stool specimen to lab.*
Standard work for handwashing
Reviewed at until huddles
Created small poster depicting standard work of handwashing
Handwashing
Poster placed at every sink in the organization (staff and visitor).*
Patient and visitor education sheet on proper handwashing technique
Invite visitors to wash their hands at nurses’ station.
Standard work for doffing PPE
Reviewed until huddles
Doffing PPE Created small poster depicting standard work of doing PPE
Poster placed at doorway of every C. diff/contact isolation room.*
Patient and visitor education sheet of every C. diff on use of PPE and proper doffing
CAUTI
Policy update to reflect current evidence-based reasons for insertion
Add female urinals to all unit supply.*
Evaluate various catheter insertion kits and make recommendation to supply chain.
Update provider order sets to not have urinary catheter prechecked and add reasons for
Indwelling catheter insertion insertion to order.
Start communication campaign to update staff on indwelling catheter current evidence-
based practice (e.g., Do not inflate balloon prior to insertion, straight catheterization is
potentially a better option than an indwelling for some patients). Present this information
in unit huddles.
CLABSI
Partnering with central line and PICC vender to assess issues with CLABSI and develop
Insertion and maintenance
interventions
Dissemination of Data
Quality boards created to display data for each HAI
“Real time” case review of fallouts and near misses
Quality boards and huddles
Data and fallout information discussed at until shift huddles.
Improvement ideas solicited from frontline staff
* Interventions recommended as improvement ideas from frontline staff

CAUTI = catheter-associated urinary tract infection, CLABSI = central line associated bloostream infection, C. diff =
Clostridium difficile, HAI = hospital-acquired infection, PPE = personal protective equipment, PICC = peripherally inserted cen-
tral catheter

encounter barriers with their
improvement activities.
Daily management and moni-
toring of HAI events was the first
intervention of the workgroup.
The team has supported the IP
department in their effort with
providing “real time” notification
of and information on HAI cases.
Information technology and ana-
lytical support personnel assist in
delivering HAI-related data to aid
this rapid cycle improvement
process.
When the IP team learns of a
HAI from laboratory results, they
immediately notify the patient’s
unit nursing manager and direc-
tor. The nursing manager, HAI
workgroup representatives, and IP
conduct a case review within 1

NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3 133

 business day on each HAI inci-
dent to review the causes of the
infection and to develop interven-
tions to prevent future HAIs. The
team writes a synopsis of the case
(see Figure 1). Quality boards on
each unit are updated at least
weekly with current HAI occur-
rence data, evidence-based inter-
ventions to help mitigate a HAI,
daily evaluation of practice out-
comes related to the response,
case reviews, and solicitation of
ideas for improvement from staff.
Unit leadership disseminate qual-
ity board data and interventions at
shift huddle and during meetings
and encourage staff to discuss HAI
problems and possible solutions.
The HAI workgroup is imple-
menting a consistent process to
drive improvement in the organi-
zation. They are using the IHI
Model for Improvement and the
Plan-Do-Study-Act (PDSA) model
for continuous improvement (IHI,
2018b). Evidence-based practice
resources, national guidelines,
and bundles are used to update
policies to reflect the latest evi-
dence and standards. The organi-
zation’s quality and process
improvement specialists guide the
HAI workgroup in using tools to
identify cause and effect reasons
for HAIs. From identified causes
and policy updates, the team pri-
oritizes focus areas for evaluation
and intervention.
One intervention was crafting
an audit tool for frontline nurses
and physicians to use when decid-
ing to collect a C. diff specimen.
The audit tool ensures appropriate
samples are sent to the lab.
Examples of workgroup interven-
tions include creating official
work posters that describe and
show suitable techniques for
washing hands and doffing PPE.
Products are evaluated to ensure
the best infection prevention
products are available. The cen-
tral-line port hubs were changed
in January 2017, and there has not
been a CLABSI since the change.
A complete list of workgroup
interventions to date is shown in
134
Table 4. Audits are conducted on
focus areas pre and post-interven-
tion. Results of these audits are
reviewed to determine next steps
on each issue.
The HAI team and their front-
line colleagues have taken the
risks that HAIs pose to the organi-
zation seriously. The staff have
given feedback they appreciate the
real-time information and support
on HAI cases. Real-time review of
each HAI provides the team a per-
sonal connection to the data.
Frontline staff have been engaged
in the interventions, and their
improvement ideas have been
implemented. A staff member rec-
ommended placing the official
work posters for handwashing and
doffing PPE adjacent to infection
prevention signage at a patient’s
room doorway. This reminds staff
to follow that standard work each
time they enter or exit the room. It
also has been used to help educate
family and visitors to appropriate
handwashing and utilization of
PPE. Other staff improvement
ideas that have been implemented
are noted in Table 4.
Results
The HAI team was formed in
January 2017. The 2017 count of
HAIs through mid-December was
47 compared to 80 during the same
time period in 2016 (41% reduc-
tion). This reduction amounts to a
$380,000 in savings to the organiza-
tion. The workgroup will continue
to work on cost-avoidance efforts,
focusing on other root cause issues
of HAIs and ensuring sustainment
of improvement.
Implications for Practice
Several factors have led to the
successful decrease in HAIs. First,
the HAI workgroup is interprofes-
sional and most members are front-
line staff. The team focused on
researching current evidence, to
understand the risk and calculate
the cost HAIs pose to patients and
the organization. The HAI work-
group’s commitment in using the
IHI Model for Improvement and
NURSING ECONOMIC$/May-June 2018/Vol. 36/No. 3
PDSA process was key. Use of
these tools required the team to be
disciplined in understanding and
gathering data about problems con-
tributing to HAIs before jumping to
solutions.
Other contributing factors to
success were the team’s engage-
ment with all hospital staff mem-
bers. Reviewing HAI fallouts, writ-
ing the story, providing lessons
learned and recommendations,
and disseminating the story along
with updated data during unit
huddles was well received by
frontline department colleagues.
Those colleagues also offered valu-
able improvement ideas; many of
which were implemented by the
team.
Conclusion
Hospital-acquired infections
pose a significant threat to health
care and healthcare organizations.
HAIs cause patient safety, ethical,
regulatory, financial, and legal risk.
The rate of HAIs in 2016 did not
align with the mission, vision, or
strategic plan of the organization
and action had to be taken. The
HAI workgroup is leading im-
provement efforts that require
every individual in the organiza-
tion to be engaged in the improve-
ment efforts. Understanding root
causes, following the IHI Model for
Improvement to deploy interven-
tions, communicating HAI stories
to the frontline, and implementing
staff improvement ideas have all
proven effective in addressing
HAIs. The community, patients,
and the organization’s reputation
as a quality provider of healthcare
depend on these continuous
improvement efforts. $
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