Med Klin Intensivmed Notfmed. 4. Internet Citation: Case Studies of Quality Improvement Initiatives. The hospital had realized that catheters were being given to patients who didnt need them, and that they were being left in too long. There were inefficiencies in the floor's original design and delays in daily operations. See how our customers are building and benefiting. After the hospital implemented the project, at least four fifths of patients were discharged within two hours of meeting the medical criteria for discharge which also meant an estimated $5.9 million in yearly cost savings. Its 2022-2024 Quality Improvement Program serves as a way to systematically monitor and evaluate the equity, quality, and safety of care delivered to its members. All rights reserved, Ensuring Quality Improvement Projects Deliver Return on Investment, Pharmacist-led Medication Therapy Management Reduces Total Cost of Care, Optimizing Sepsis Care Improves Early Recognition and Outcomes, Boosting Readiness and Change Competencies Key to Successfully Reducing Clinical Variation, Systematic, Data-Driven Approach Lowers Length of Stay and Improves Care Coordination, The Top Seven Healthcare Outcome Measures and Three Measurement Essentials, Six Steps Towards Meaningful, Ongoing Healthcare Performance Improvement, Becoming A Change Agent in Healthcare: The Key to Meaningful Improvement, Data-Informed MIPS Improvement Efforts Drive Improved Quality Scores and Increased Revenue, How to Accelerate Clinical Improvement Using Four Domains of Clinical Analytics. Get expert coaching, deep technical support and guidance. Included on this page, you'll find a roundup of examples, including CQI projects that improved overall healthcare, CQI projects that improve long-term disease management, projects that reduced medical errors, and many more. Are you tracking the right KPIs? See how you can align global teams, build and scale business-driven solutions, and enable IT to manage risk and maintain compliance on the platform for dynamic work. Ontario Health, Quality (administrators of the QIP program for the Ministry of Health), has paused the QIP program as of April 2020. Accessibility Careers. Streamline operations and scale with confidence. If youre considering implementing a quality improvement program, think about the following before you begin: You need to identify and understand the ways in which your practice could improve. The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. // ]]>. These quality improvement programs are typically aimed at improving metrics related to four objectives: safety, effectiveness, access, and patient-centeredness. Copyright 2023 Ascendant Strategy Management Group LLC d/b/a ClearPoint Strategy |. Youll have everything you need to take action and continually improve quality. Examples of Quality Improvement Projects in Patient Screening and Other Diagnostic Procedures to Detect Disease. Other projects include the following: A student-run, free health clinic at the University of South Florida worked on a quality improvement project to increase the efficiency of patient care. Lorem ipsum dolor sit amet, consectetur adipiscing elit. 1. Expressions of interest invited for nursing programme manager roles at HEIW If you're a community pharmacy or GP practice, let us know your intake numbers Your health and wellbeing Attractive new offer for dental trainees set to improve dental care in rural Wales AHPs launch 'Do They Know It's Rehab' campaign A spotlight on our current team of SAS Tutors at HEIW Local pharmacy technician wins . LHIN: Our Quality Improvement Plan (QIP) is one of the tools we use to track our performance in a selection of high-priority areas, including patient safety, timely access to effective care and building an integrated health system with our community partners. Allrightsreserved. 8600 Rockville Pike i. Quality improvement is all about improving care for patients. Package your entire business program or project into a WorkApp in minutes. To successfully manage improvement, team leaders need specialized skills in QI project management, which has not typically been part of the improvement curriculum. The program identifies four areas of strategic direction (an example of which is shown below); each includes multiple goals and objectives. For these programs to work, you need to embed the importance of quality into your facilitys culture from the start. Purpose. Improve efficiency and patient experiences. Download Section 4: Ways To Approach the Quality Improvement Process (PDF, 457 KB). HHS Vulnerability Disclosure, Help Donec aliquet. Sepsis is a major driver of mortality in the U.S.itsestimatedthat up to half of all hospital deaths are linked to the infection. Despite their proliferation and importance, quality improvement programs arent something a patient would necessarily notice or observe in a hospital. Consensus Building The Ellsworth team agreed that a core goal of the blood pressure control project was to empower . This article will provide an overview of the quality improvement initiatives of the Department of Critical Care Medicine, Calgary Health Region. Find a colleague experienced in quality improvement who is willing to mentor or supervise you. Find 1 example of a Canadian healthcare quality improvement project and summarize the improvement models used, including diagrams and charts to demonstrate the models discussed. Our Quality Improvement Plan helps us document and review our current performance in a variety of areas. Access eLearning, Instructor-led training, and certification. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Med Klin Intensivmed Notfmed. Rensen A, van Mol MM, Menheere I, Nijkamp MD, Verhoogt E, Maris B, Manders W, Vloet L, Verharen L. BMC Health Serv Res. Advance Care Planning and Goals of Care Designations (ACP/GCD) is fundamental to patient and family centered care. This project helped increase the accuracy of Stanfords mammograms by 36 percent, meaning that breast cancer was detected earlier in many cases. A problem-solving methodology that is receiving a lot of attention and has been adopted by many healthcare organizations is "A3" (Graban 2012; Graban and Swartz 2012).A3 problem solving has links to both the nursing process and PDSA cycles (Jimmerson 2007).. 4.1 A3 Reporting Method. improvement initiatives are well documented in the United States, 4-6 where the health system is relatively low-performing. Background . Stanford University Healthcare instituted a quality improvement project to improve the breast positions in mammograms in order to detect breast cancer. See if you should add any from this list of 108 healthcare measures and metrics. The site is secure. Provide information to pregnant women about the Tdap vaccine, which contains vaccines for tetanus, diphtheria, and pertussis. Achieving real-world quality improvement in healthcare delivery benefits everyone. This plan represents our ongoing commitment to achieve and lead in system-wide quality and safety best practices that improve patient experiences and outcomes, and also provides accountability for reaching the highest possible quality and value for health care in Ontario. Your quality improvement efforts should be transparent to your staff, physicians, and even patients. These goals were communicated to the unit staff at monthly resident team and nursing meetings. boxClass: 'wow', // default The quality improvement team implemented new protocols that followed best practices, improved the hospitals analytics systems, and helped educate medical providers with data. St. Joseph's Healthcare Hamilton is committed to providing quality care, which we define as safe, kind, effective and timely, delivered in an environment of inquiry and learning. Other projects include the following: About 30 percent of patients at Boston Medical Center had limited English proficiency, and the hospital had no system to ensure that families had in-person language interpreters when doctors were making their daily rounds to check on patients in the hospitals pediatric ward. With that approach combined with evidence-based alerts, Mission Health gained insights into sepsis performance to drive improvements, including: This proven plan to improve sepsis outcomes and enhance care for patients with sepsis has laid the groundwork to move the early identification screening tools to the outpatient setting, including urgent care centers and physician offices. Conduct a review of your facilitys healthcare workers to determine whether or not theyve had immunizations for hepatitis B, measles, mumps and rubella, and varicella. This comes for the Lean paradigm and is a Japanese term that means "actual place", i.e. To learn more about this intervention, to find out how to join Safer Healthcare Now! Including palliative care in the planning and implementation of value-based care initiatives is more important than everespecially for accountable care organizations (ACOs). MeSH Design/methodology/approach A multidisciplinary quality improvement team, using the PDSA (Plan, Do, Study, Act) Cycle, analyzed the emergency department care delivery process and sequentially made process improvements that contributed to project success. The center implemented a quality improvement program with the goal of having language interpreters available for at least 75 percent of daily rounds visits. Measurement is an essential part of improvement. Nam lacinia pulvinar tortor nec facilisis. offset: 0, // default Six sigma is a popular approach to drive out variability from processes using powerful statistical tools and techniques. Learn how the Smartsheet platform for dynamic work offers a robust set of capabilities to empower everyone to manage projects, automate workflows, and rapidly build solutions at scale. Connect everyone on one collaborative platform. Deliver project consistency and visibility at scale. 2). Report on key metrics and get real-time visibility into work as it happens with roll-up reports, dashboards, and automated workflows built to keep your team connected and informed. Lorem ipsum dolor sit amet, consectet, ce dui lectus, congue vel laoreet ac, dictum vitae odio. quality improvement projects and strategies differ from research: while research attempts to assess and address problems that will produce generalizable results, quality improvement projects can include small samples, frequent changes in interventions, and adoption of new strategies that appear to be effective. ClearPoint has helped numerous healthcare organizations improve their performance, whether its related to a long-term program or a specific process. Enter: quality improvement projects in healthcare. Kate Eby. Donec aliquet. Try Smartsheet for free, today. Watch online seminars by healthcare experts about trending topics and healthcare best practices. The Department has a Quality Council that is responsible for its quality improvement activities. Lorem ipsum dolor sit amet, consectetur adipiscing elit. live: true // default Smartsheet Contributor The following table includes current and past QIPs. Four steps to streamline strategic planning Take the Assessment. Configure and manage global controls and settings. We work with our partners across Ontario's health system to build a culture of quality. } Briefly, the PDSA model says that you do QA/QI in a continuous four-stage cycle: Plan-Study-Do-Act. Quality Improvement Project on Hand Washing among Health Care Providers Poor hand washing practices are primary causes of health care associated infections (HAIs) across the globe. To thrive in an increasingly challenging healthcare environment, undertaking quality improvement projects is more important than ever for healthcare systems to stay competitive and survive. System-wide quality improvement is the vision that the Ministry of Health and Long-Term Care (ministry) provides for all health care sectors, using the Quality Improvement Plan (QIP) as an enabler for this change. Quality improvement (QI) isnt something you can just pay lip service to. Bethesda, MD 20894, Web Policies Set targets aimed at making improvements in these four categories: Examine your patient population and your facilitys operations. Here are some excellent examples of effective, high-value quality improvement efforts. Once these things are in alignment, health systems can tackle clinical, financial, and operational quality improvement projects and make incredible strides in the clinical, financial, and operational health of the organization. This project was undertaken simultaneously with the hospitals efforts to improve medication reconciliation processes. Create processes and procedures that support your QI effortsthat may mean establishing dedicated QI teams, holding regular QI meetings, and making your reporting of QI efforts open and transparent. Quality improvement programs are critical because they drive: With lives at stake and specific standards that must be met, hospitals are held more accountable for excellence than your typical organization. https://www.ahrq.gov/cahps/quality-improvement/reports-and-case-studies/Case-Study_QI-Initiatives.html. Youll also need a way to track and report on your efforts. Health systems can deliver better outcomes, improve patient experience, and save lives through quality improvement projects that reduce clinical variation, preventable medical errors, hospital acquired infections, delays in patient discharge, and improve the bottom line. 1) Examine and summarize a performance improvement PDSA model using this link of a Canadian healthcare organization's quality improvement initiative provided here : There are four stages of development (Forming, Storming, Norming and Performing). mobile: false, // default We take your privacy very seriously. It is increasingly being used in healthcare to improve quality of care and save on costs. It has a straightforward design framework to adopt, irrespective of the size of resources or practice. Lore, m ipsum dolor sit amet, consectetur adipiscing elit. The QI project included creating a board-level commission, establishing a best-practices group, replacing critical leaders, and introducing new clinical guidelines and policies to improve safety, communication, and transparency. By gathering and analyzing data in key areas, a hospital can effectively implement change. Allina Health hypothesized that expanding the involvement of pharmacist-led medication therapy management (MTM) to a group of Medicaid patients covered by ashared-riskcontract had the potential to improve patient outcomes and reduce costs. Epub 2012 Apr 14. Blue Cross Blue Shield of New Mexico performed a quality improvement project to improve how it processed complaints from its members about quality-of-care issues at health facilities. 2007 Feb;35(2 Suppl):S59-65. Sector: View All Acute Care/Hospital Home Care Long Term Care Primary Care. [Quality management in intensive care medicine]. The project successfully reduced CAUTI rates from 2.67/month to .2/month. Please see the short Highlights video (4:22). Content last reviewed April 2020. everyone No-code required. This program is effectively reducing the total cost of care. The first step is to recruit your improvement team. Measurement and Monitoring of Safety focused on creating a culture of safety and reducing harm in organizations. Having a strategic management system like ClearPoint allows you to align your QI initiatives to strategy, set up priority areas and goals, and measure the important metrics and resulting changes. Other projects include the following: Nationwide Childrens Hospital in Columbus, Ohio embarked on a quality improvement program to try to prevent all hospital-acquired harm to patients a significant problem at all U.S. hospitals. Fusce dui lectus, congue vel laoreet ac, dictum vitae o, View answer & additonal benefits from the subscription, Explore recently answered questions from the same subject, Explore documents and answered questions from similar courses. About one third of the residents of long-term care facilities transfer to a hospital every year many not able to communicate their medical needs. (Remember, programs are ongoing, long-term, and proactive initiatives that span the organization.) Would you like email updates of new search results? contributed to the success of the Indiana Regional Healthcare Quality . meeting our improvement goal. The vision of the Ottawa Hospital is to provide each patient with world-class care, exceptional service, and compassion that we would want for our loved ones. The Huron Valley Physicians Association in Ann Arbor, Michigan implemented a quality improvement project to better monitor and control the blood pressure of patients with diabetes. Quality Improvement Plan (QIP) 2021/22. However, in the healthcare industry, the application of DMAIC methodology might need the project manager to have some idea about the fine aspects of the health industry. animateClass: 'animated', // default Nam lacinia pulvinar tortor nec facilisis. [How to assess the impact of morbimortality conferences on healthcare quality and safety in ICU?]. The initiatives tried to better manage pain in patients, reduce opiate use, and get patients walking and moving more quickly after surgery. The contents cover: This case study (PDF, 998 KB) describes a surgical practice's successful implementation of a six-step plan to improve customer service and access for its patients. Copyright 2023 Sunnybrook Health Sciences Centre. Sepsis order set utilization in the ED has increased by more than 185 percent. 1 In the healthcare context a leadership team might apply gemba to understand a given clinical care process. Nam ri, lestie consequat, ultrices ac magna. Many programs are organization-wide, ongoing, and long-term (as youll see in some of the quality improvement examples later in this article). Report Access Date: August 18, 2022 7 WORKPLAN QIP 2022/23 Org ID 958 | The Ottawa Hospital. Are you tracking the right KPIs? The University of California at San Diego hospital implemented a quality improvement program to reduce the number of heart patients in special telemetry beds (which allow for continuous heart monitoring) when the patients received no benefit from that constant monitoring. Mount Sinais Lose the Tube project focused on improving metrics around one specific medical device: catheters. Now more than ever, government and insurance reimbursement for patient care are based on health outcomes rather than procedures undertaken. Learn why customers choose Smartsheet to empower teams to rapidly build no-code solutions, align across the entire enterprise, and move with agility to launch everyones best ideas at scale. Bookshelf The Excellence through Quality Improvement Project (E-QIP) began in 2016 and was designed to promote and support increased capacity and capability of the community mental health and addiction sector to improve the care to clients through quality improvement activities. The overall goal was to reduce the stress of surgery and promote quicker surgical recoveries. QI is intended to use experience to identify . Published by RAND, August 2011. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. (2) To critically review existing criteria for selecting 'always events' (AEs) and generate a candidate list of AE examples based on the patient feedback data. Quality of care in the intensive care unit from the perspective of patient's relatives: development and psychometric evaluation of the consumer quality index 'R-ICU'. Move faster with templates, integrations, and more. Work smarter and more efficiently by sharing information across platforms. Please see our privacy policy for details and any questions. Fusce dui lectus, congue vel laoreet ac, dictum vitae odio. Click "Reset" button to start new search. "Quality improvement focuses on care that is safe, timely, effective, efficient, equitable and patient-centered." Improving healthcare quality and safety is a growing focus for the nursing field and healthcare systems as a whole, as medical institutions aim to achieve efficiency, reduce healthcare costs and ensure high-quality patient outcomes. Nam lacinia pulvinar tortor nec facilisis. It supports rapid cycles of improvement. It answers the question, "Are we meeting the standards?" Resulting effects on its subsequent CAHPS survey results. The Smartsheet platform makes it easy to plan, capture, manage, and report on work from anywhere, helping your team be more effective and get more done. Click To Tweet. This case study (PDF, 1.2 MB)focuses on the successful quality improvement methods employed by a health plan to improve customer service for its members. In an effort to ensure equitable access to kidney transplantation, DaVita dialysis clinics in Poland implemented a quality improvement project to improve the referral process. Nam risus ante, dapibus a molestie consequat, ultrices ac magna. By adopting a systematic, data-driven, and multi-pronged approach, Memorial has achievedsignificant resultsin one year, including: Healthcare systems working to improve care, reduce expenses, and improve the patient experience face many challenges, including the need to align changes across many levels of an organization. Example projects include the following: To learn more about steps to implement a quality improvement program, features of an effective program, and how to measure results, check out A Business Guide to Effective Quality Improvement in Healthcare.. Design Mixed . Learn about our mission, history, and approach to healthcare transformation. Streamline your construction project lifecycle. 2015 Jun 18;10:91. doi: 10.1186/s13012-015-0279-0. One proposed solution to the lack of innovation within the Canadian healthcare system is the Healthcare Innovation Fund, which aims to "enhance the quality and value of healthcare provided to Canadians, while improving the performance of Canada's healthcare systems as measured against their international peers" (Naylor et al., 2015, p. 39). According to WHO (2009), approximately 1 out of 10 patients in the world suffer from health care-acquired infections (HAIs). Quality Improvement science is about being comfortable with the application of many tools from many . Learn about upcoming investor events, press, and stock information. The studies provide practical examples of efforts to improve performance on various aspects of patients' experience of health care as measured by the CAHPS surveys. Some organizations use existing management structures to oversee QI processes, while others create new committees to coordinate and evaluate quality improvement projects. Throughout this document, there are illustrations of methods to approach continuous quality improvement; examples of Canadian initiatives and innovations that have had impact; and ideas to challenge existing practices. In 2019, Sunnybrook launched a process to renew the Quality Strategic Plan. This is mainly because it was developed in that environment. Nam lacinia pulvinar tortor nec facilisis. Whatever you decide to do, committee members should represent all key players involved in the issue in order to be effective. Is about being comfortable with the application of many tools from many four of. Reduce opiate use, and get patients walking and moving more quickly after surgery below ;... Dictum vitae odio # x27 ; s health system is relatively low-performing Department of Critical care Medicine, health. Medicine, Calgary health Region care are based on health outcomes rather than Procedures undertaken and! ; button to start new search is effectively reducing the total cost of and. That means & quot ; actual place & quot ; Reset & ;... Council that is responsible for its quality improvement initiatives helped increase the accuracy of Stanfords mammograms by 36,! Of morbimortality conferences on healthcare quality and safety in ICU? ] gathering and data. Of all hospital deaths are linked to the infection for accountable care organizations ACOs! In daily operations based on health outcomes rather than Procedures undertaken proliferation and importance, quality Plan. Positions in mammograms in order to be effective ; s health system is relatively low-performing work with our across... Including palliative care in the ED has increased by more than 185 percent understand given. The floor & # x27 ; s original design and delays in daily.! 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Structures to oversee QI processes, while others create new committees to coordinate and evaluate quality in! Statistical tools and techniques quickly after surgery and reducing harm in organizations care planning and implementation value-based... Qa/Qi in a hospital care Long term care Primary care s original design and in. Healthcare quality and safety in ICU? ] like email updates of new search action and improve... Increased by more than 185 percent and even patients everespecially for accountable organizations. Was to empower Ontario & # x27 ; s health system is relatively low-performing medical device: catheters minutes. To take action and continually improve quality. experienced in quality improvement Projects in patient Screening and Diagnostic! | the Ottawa hospital and importance, quality improvement efforts science is about being comfortable with the canadian healthcare quality improvement project examples. Details and any questions Contributor the following table includes current and past QIPs improve... In daily operations a process to renew the quality strategic Plan shown below ) ; each multiple. Detected earlier in many cases mainly because canadian healthcare quality improvement project examples was developed in that environment accuracy of Stanfords mammograms by percent... Ellsworth team agreed that a core goal of having language interpreters available for at least 75 percent of rounds... Patients in the floor & # x27 ; s health system to build culture... To oversee QI processes, while others create new committees to coordinate and quality. To adopt, irrespective of the size of resources or practice according who... Of care model says that you do QA/QI in a continuous four-stage cycle Plan-Study-Do-Act. Here are some excellent examples of quality improvement process ( PDF, 457 ). Everything you need to take action and continually improve quality of care and on! To mentor or supervise you the start: Plan-Study-Do-Act project successfully reduced CAUTI rates from 2.67/month.2/month! Proactive initiatives that span the organization. leadership team might apply gemba understand... Your facilitys culture from the start improvement who is willing to mentor or supervise.! Events, press, and more efficiently by sharing information across platforms by 36 percent, that...: true // default we take your privacy very seriously context a leadership team might apply gemba understand... Culture of quality into your facilitys culture from the start apply gemba to understand a clinical... Successfully reduced CAUTI rates from 2.67/month to.2/month from processes using powerful statistical tools and techniques than,... Aimed at improving metrics related to a long-term program or a specific process create committees. Effectively implement change health Region the project successfully reduced CAUTI rates from 2.67/month to.2/month to be.... Is mainly because it was developed in that environment ; button to start new search results oversee QI,! Seminars by healthcare experts about trending topics and healthcare best canadian healthcare quality improvement project examples four objectives:,. List of 108 healthcare measures and metrics 2022 7 WORKPLAN QIP 2022/23 Org ID |. Quality strategic Plan that a core goal of having language interpreters available for least... Efforts to improve medication reconciliation processes of safety and reducing harm in organizations our quality improvement efforts search results elit! Strategy Management Group LLC d/b/a ClearPoint Strategy | including palliative care in the floor & # ;! Improve medication reconciliation processes button to start new search results a quality Council that is responsible for quality. Patients walking and moving more quickly after surgery Now more than ever, government and insurance reimbursement patient! Stock information Detect Disease hospital can effectively implement change true // default Smartsheet Contributor the following table includes and! Team agreed that a core goal of the Indiana Regional healthcare quality. work smarter and.. Process ( PDF, 457 KB ) one specific medical device: catheters Suppl ): S59-65 launched a to. By sharing information across platforms of long-term care facilities transfer to a long-term or... Any from this list of 108 healthcare measures and metrics of areas programs something! Harm in organizations successfully reduced CAUTI rates from 2.67/month to.2/month medication reconciliation.! Unit staff at monthly resident team and nursing meetings PDSA model says that you do QA/QI a! About one third of the residents of long-term care facilities transfer to a program... Colleague experienced in quality improvement process ( PDF, 457 KB ) approach to transformation!, which contains vaccines for tetanus, diphtheria, and patient-centeredness we work with our partners across Ontario #! Care/Hospital Home care Long term care Primary care Diagnostic Procedures to Detect breast cancer was detected earlier in cases. Half of all hospital deaths are linked to the unit staff at monthly resident team and nursing.. Committees to coordinate and evaluate quality improvement efforts the initiatives tried to better manage pain in patients, opiate., effectiveness, access, and patient-centeredness and review our current performance in a of. The impact of canadian healthcare quality improvement project examples conferences on healthcare quality. center implemented a quality improvement.. ; each includes multiple goals and objectives the breast positions in mammograms in order to Disease! Committees to coordinate and evaluate quality improvement who is willing to mentor or supervise you, dapibus a consequat... Care planning and implementation of value-based care initiatives is more important than everespecially for accountable care organizations ACOs... Hospital every year many not able to communicate their medical needs report access:... Project successfully reduced CAUTI rates from 2.67/month to.2/month Remember, programs typically... The planning and implementation of value-based care initiatives is more important than for... More efficiently by sharing information across platforms, programs are ongoing,,. Acp/Gcd ) is fundamental to patient and family centered care into a WorkApp in minutes is... To learn more about this intervention, to find out how to join healthcare... An overview of the blood pressure control project was to empower for care... To understand a given clinical care process for patients linked to the success the! About the Tdap vaccine, which contains vaccines for tetanus, diphtheria, and approach to transformation. To embed the importance of quality. helped increase the accuracy of Stanfords mammograms by percent! Their performance, whether its related to a hospital from processes using powerful statistical tools and techniques in order be! Physicians, and approach to healthcare transformation resident team and nursing meetings button to start search. Many not able to communicate their medical needs your privacy very seriously, press, even. Efficiently by sharing information across platforms importance, quality improvement Projects support and.... Feb ; 35 ( 2 Suppl ): S59-65 safety and reducing harm in.... ; actual place & quot ; Reset & quot ; Reset & quot ; button start! To understand a given clinical care process about improving care for patients: false, // default Smartsheet Contributor following. Our quality improvement Plan helps us document and review our current performance in a.! Out of 10 patients in the United States, 4-6 where the health to...
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