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Please answer the attached template using the capstone study E help file as needed. Thank you
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CAPSTONE CASE
E
Quality of Care in Seven
Boston Hospitals
EPIDEMIOLOGY AND QUALITY OF
CARE
How can quality of care be measured?
STRUCTURE
PROCESS
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
OUTCOME
STRUCTURE METHODS
o Related to personnel/facilities and their
configurations
o Does facility meet fire code?
o Is facility clean?
o Are physicians licensed?
o What is the ratio of RNs to total nurses?
o STRUCTURE measures: PRO
o
Information readily obtained from existing
documents/inspection
o STRUCTURE measures: CONs
Assumes STRUCTURE → PROCESS → OUTCOME
o Has not been validated
o
Copyright 2015 Foundation of the American College of Healthcare Executives.
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PROCESS MEASURES
o Refers to what is done to the patient; the
sequence/coordination of activities
o “Technical” aspect of care
o Activities of professionals
o The “science” of care
o Interpersonal aspects of care
o How the patient was treated
o The “art” of care
o Donabedian argued that some of the “art” may be
referring to technical care; thus the technicalscience/interpersonal-art idea does not hold
completely
o Amenities of care
o How appealing/comfortable the facilities are
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
PROCESS MEASURES
o PROs
o Operationally easier to collect than outcome
measures
Less time dependent
o Less dependent on expensive patient follow-up
o Medical record does record certain aspects of process
of care
o
o CONs
o Depends on agreed-upon criteria for care
o Clinicians don’t think in terms of lists
o They think on a contingency basis
o
o
Signs/symptoms/severity? → Tests → Check tests, etc.
Outcomes are what is really important
o
Assumes PROCESS → OUTCOME
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
KINDS OF PROCESS MEASURES
o EXPLICIT criteria
o The “laundry list” approach
o Elements of good care listed
o IMPLICIT criteria
o Unspecified rules that an expert uses when asked to
review a medical record
o Criteria mapping, clinical guidelines, critical
pathways
More like how clinicians think
o Good care met in many ways depending on
o
Signs/symptoms
o Lab test results
o Severity
o
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
OUTCOME MEASURES
o
Refers to the net changes in health status as a result of care
o General health status indicators
o Multidimensional: may use physical/social/mental
o Reflect changes in several dimensions of health but may
be too sensitive to nonmedical factors
o Based on own perceptions of health or others’ (e.g., doctors’)
assessment
o The Sickness Impact Profile
o Intermediate outcomes of care
o If final outcome (e.g., death avoidance) many years in future
o e.g., see if blood pressure reduced
o Disease-specific indicators
o e.g., death rates/symptoms/disabilities associated with a
specific disease
o Look at adverse outcomes of care
o e.g., infections after surgery
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
OUTCOME MEASURES
o
PROs
o Outcomes are what is really important
o Have high face validity; conceptually make
sense
o CONs
o Must obtain information from patients if not in
medical record → costly because survey must
be taken
o Must adjust measures for severity of illness
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
HOW ARE JUDGMENTS MADE?
o Criteria
o Elements, components, attributes, characteristics of structure,
process, or outcome
o Norms
o Rules of “goodness”
Presence of something better than absence
o Larger is better than smaller
o
o Standards
o Quantitative measure to define goodness
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
EXAMPLES
o Criteria
o Number of nurses per bed
o Blood pressure
o Norm
o Not too many nor too few
o Lower blood pressure is better, but not too low
o Standard
o One RN per 10–20 beds
o 70 percent of patients treated for hypertension
should have blood pressure in defined range
within one year of treatment
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
EXHIBIT E.1
STRUCTURE MEASURES
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.2
TIMELY AND EFFECTIVE CARE CRITERIA (NOT EXHAUSTIVE
LIST)
Copyright 2015 Foundation of the American College of Healthcare Executives. Not for sale.
EXHIBIT E.2
TIMELY AND EFFECTIVE CARE CRITERIA (NOT EXHAUSTIVE
LIST)
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.3
CENTRAL LINE AND CATHETER INFECTIONS
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EXHIBIT E.3 (CONTINUED)
CENTRAL LINE AND CATHETER INFECTIONS
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.4
SURGICAL SITE INFECTIONS
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EXHIBIT E.4 (CONTINUED)
SURGICAL SITE INFECTIONS
Copyright 2015 Foundation of the American College of Healthcare Executives. Not for sale.
EXHIBIT E.6
30-DAY MORTALITY RATES
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EXHIBIT E.6 (CONTINUED)
30-DAY MORTALITY RATES
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.6 (CONTINUED)
30-DAY MORTALITY RATES
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.6 (CONTINUED)
30-DAY MORTALITY RATES
Copyright 2015 Foundation of the American College of Healthcare Executives. Not for sale.
EXHIBIT E.7 30-DAY READMISSION RATES
#readmitted
Copyright 2015 Foundation of the American College of Healthcare Executives. Not for sale.
#readmitted
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
Copyright 2015 Foundation of the American College of Healthcare Executives.
Not for sale.
EXHIBIT E.8
PATIENT SAFETY INDICATORS
Copyright 2015 Foundation of the American College of Healthcare Executives. Not for sale.
EXHIBIT E.8 (CONTINUED)
PATIENT SAFETY INDICATORS
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.8 (CONTINUED)
PATIENT SAFETY INDICATORS
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.8 (CONTINUED)
PATIENT SAFETY INDICATORS
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
EXHIBIT E.8 9 (CONTINUED)
PATIENT SAFETY INDICATORS
Copyright 2015 Foundation of the American College of Healthcare
Executives. Not for sale.
Name?
CASE E: QUALITY OF CARE IN SEVEN BOSTON HOSPITALS
Please erase ?, …, and ___ – Please use a different color than black for your answers!!!!!!!
1. (please indicate hospitals’ names and measures lacking)
Based on Exhibit E1. The hospitals that lack measures that are indicative of the capacity
to provide care are: …
2. The measures used by the Value-based purchasing (VBP) program are called process of
care measures because …
3. Based on Exhibit E.2 , B & W Hospital exceeds both state and national benchmarks in …
However, B & W Hospital has lower averages for …
4. Exhibit E.3 – Please fill in values for highlighted Standardized Infection Ratio (SIR)
column
Exhibit E.3 Central Line and Catheter Infections
Central Line–Associated Bloodstream Infections
Actual Expected
Lower
Hospitals
Cases
Cases
SIR
CI
Brigham and Women’s Hospital
22
41.578
0.331
Tufts Medical Center
10
26.655
0.18
Brigham and Women’s Faulkner Hospital
0
1.744
NA
New England Baptist
1
1.333
0.019
Boston Medical Center
3
24.067
0.026
Beth Israel Deaconess Medical Center
15
30.307
0.277
Massachusetts General Hospital
38
66.796
0.403
Catheter-Associated Urinary Tract Infections
Actual Expected
Lower
Hospitals
Cases
Cases
SIR
CI
Brigham and Women’s Hospital
89
60.273
1.186
Tufts Medical Center
37
22.699
1.148
Brigham and Women’s Faulkner Hospital
3
3.326
0.186
New England Baptist
2
1.641
0.148
Boston Medical Center
31
25.753
0.818
Beth Israel Deaconess Medical Center
73
38.408
1.49
Massachusetts General Hospital
200
86.371
2.006
1
Upper
CI
0.801
0.69
2.115
4.18
0.364
0.816
0.781
Compare
to US
Upper
CI
1.817
2.247
2.636
4.403
1.709
2.39
2.66
Compare
to US
5. Exhibit E.3 – Please fill in values for the highlighted Compare to US column
Exhibit E.3 Central Line and Catheter Infections
Central Line–Associated Bloodstream Infections
Actual Expected
Lower
Hospitals
Cases
Cases
SIR
CI
Brigham and Women’s Hospital
22
41.578
0.331
Tufts Medical Center
10
26.655
0.18
Brigham and Women’s Faulkner Hospital
0
1.744
NA
New England Baptist
1
1.333
0.019
Boston Medical Center
3
24.067
0.026
Beth Israel Deaconess Medical Center
15
30.307
0.277
Massachusetts General Hospital
38
66.796
0.403
Catheter-Associated Urinary Tract Infections
Actual Expected
Lower
Hospitals
Cases
Cases
SIR
CI
Brigham and Women’s Hospital
89
60.273
1.186
Tufts Medical Center
37
22.699
1.148
Brigham and Women’s Faulkner Hospital
3
3.326
0.186
New England Baptist
2
1.641
0.148
Boston Medical Center
31
25.753
0.818
Beth Israel Deaconess Medical Center
73
38.408
1.49
Massachusetts General Hospital
200
86.371
2.006
Upper
CI
0.801
0.69
2.115
4.18
0.364
0.816
0.781
Compare
to US
Upper
CI
1.817
2.247
2.636
4.403
1.709
2.39
2.66
Compare
to US
6. See Exhibit E.4. Please fill in values for highlighted Standardized Infection Ration (SIR)
column
Exhibit E.4 Surgical Site Infections
Colon Surgery
Actual Expected
Hospitals
Cases
Cases
Brigham and Women’s Hospital
18
21.733
Tufts Medical Center
7
3.719
Brigham and Women’s Faulkner Hospital
0
1.51
New England Baptist
NA
NA
Boston Medical Center
2
5.58
Beth Israel Deaconess Medical Center
11
12.215
Massachusetts General Hospital
25
15.914
Abdominal Hysterectomy
Actual
Expected
Hospitals
Cases
Cases
Brigham and Women’s Hospital
5
4.895
Tufts Medical Center
3
0.922
Brigham and Women’s Faulkner Hospital
0
0.479
New England Baptist
NA
NA
Boston Medical Center
0
1.603
Beth Israel Deaconess Medical Center
2
2.616
Massachusetts General Hospital
7
3.778
2
SIR
SIR
Lower
CI
0.491
0.757
Compare
to US
NA
0.043
0.45
1.016
Upper
CI
1.309
3.878
2.443
NA
1.295
1.611
2.319
Lower
CI
0.332
NA
NA
NA
NA
0.093
0.745
Upper
CI
2.384
NA
NA
NA
2.301
2.762
3.818
Compare
to US
7. See Exhibit E.4. Please fill in values for the highlighted Compare to US column
Exhibit E.4 Surgical Site Infections
Colon Surgery
Actual Expected
Hospitals
Cases
Cases
Brigham and Women’s Hospital
18
21.733
Tufts Medical Center
7
3.719
Brigham and Women’s Faulkner Hospital
0
1.51
New England Baptist
NA
NA
Boston Medical Center
2
5.58
Beth Israel Deaconess Medical Center
11
12.215
Massachusetts General Hospital
25
15.914
Abdominal Hysterectomy
Actual
Expected
Hospitals
Cases
Cases
Brigham and Women’s Hospital
5
4.895
Tufts Medical Center
3
0.922
Brigham and Women’s Faulkner Hospital
0
0.479
New England Baptist
NA
NA
Boston Medical Center
0
1.603
Beth Israel Deaconess Medical Center
2
2.616
Massachusetts General Hospital
7
3.778
SIR
SIR
Lower
CI
0.491
0.757
Compare
to US
NA
0.043
0.45
1.016
Upper
CI
1.309
3.878
2.443
NA
1.295
1.611
2.319
Lower
CI
0.332
NA
NA
NA
NA
0.093
0.745
Upper
CI
2.384
NA
NA
NA
2.301
2.762
3.818
Compare
to US
8. See Exhibit E.5. Please fill in values for highlighted SIR column
Exhibit E.5 MRSA and C. Difficile Infections
Methicillin Resistant Staphylococcus Aureus (or MRSA) Blood Infections
Actual Expected
Lower
Upper
Hospitals
Cases
Cases
SIR
CI
CI
Brigham and Women’s Hospital
11
5.997
0.916
3.282
Tufts Medical Center
1
1.316
0.019
4.234
Brigham and Women’s Faulkner Hospital
1
0.413
NA
NA
New England Baptist
0
0.222
NA
NA
Boston Medical Center
1
3.266
0.008
1.706
Beth Israel Deaconess Medical Center
1
4.083
0.006
1.365
Massachusetts General Hospital
6
7.11
0.31
1.837
Clostridium Difficile Infections
Actual
Expected
Lower
Upper
Hospitals
Cases
Cases
SIR
CI
CI
Brigham and Women’s Hospital
25
43.602
0.371
0.846
Tufts Medical Center
14
21.001
0.364
1.119
Brigham and Women’s Faulkner Hospital
3
5.462
0.113
1.605
New England Baptist
3
4.075
0.152
2.151
Boston Medical Center
37
21.704
1.2
2.35
Beth Israel Deaconess Medical Center
42
40.415
0.749
1.405
Massachusetts General Hospital
86
69.13
0.995
1.536
3
Compare
to US
Compare
to US
9. See Exhibit E.5. Please fill in values for the highlighted Compare to US column
Exhibit E.5 MRSA and C. Difficile Infections
Methicillin Resistant Staphylococcus Aureus (or MRSA) Blood Infections
Actual Expected
Lower
Upper
Hospitals
Cases
Cases
SIR
CI
CI
Brigham and Women’s Hospital
11
5.997
0.916
3.282
Tufts Medical Center
1
1.316
0.019
4.234
Brigham and Women’s Faulkner Hospital
1
0.413
NA
NA
New England Baptist
0
0.222
NA
NA
Boston Medical Center
1
3.266
0.008
1.706
Beth Israel Deaconess Medical Center
1
4.083
0.006
1.365
Massachusetts General Hospital
6
7.11
0.31
1.837
Clostridium Difficile Infections
Actual
Expected
Lower
Upper
Hospitals
Cases
Cases
SIR
CI
CI
Brigham and Women’s Hospital
25
43.602
0.371
0.846
Tufts Medical Center
14
21.001
0.364
1.119
Brigham and Women’s Faulkner Hospital
3
5.462
0.113
1.605
New England Baptist
3
4.075
0.152
2.151
Boston Medical Center
37
21.704
1.2
2.35
Beth Israel Deaconess Medical Center
42
40.415
0.749
1.405
Massachusetts General Hospital
86
69.13
0.995
1.536
4
Compare
to US
Compare
to US
10. See Exhibit E.6 – Please fill in values for highlighted columns
Exhibit E.6. 30-Day Mortality
Acute Myocardial Infarction
30 day
Mortality
Hospitals
#Die #Cases
Rate
Brigham and Women’s Hospital
43
292
Tufts Medical Center
33
213
Brigham and Women’s Faulkner Hospital
6
37
New England Baptist
?
6
Boston Medical Center
33
215
Beth Israel Deaconess Medical Center
46
379
Massachusetts General Hospital
65
527
Congestive Heart Failure
30 day
Mortality
Hospitals
#Die #Cases
Rate
Brigham and Women’s Hospital
60
717
Tufts Medical Center
24
276
Brigham and Women’s Faulkner Hospital
28
274
New England Baptist
5
51
Boston Medical Center
42
507
Beth Israel Deaconess Medical Center
77
833
Massachusetts General Hospital
108
1,048
Pneumonia
30 day
Mortality
Hospitals
#Die #Cases
Rate
Brigham and Women’s Hospital
48
440
Tufts Medical Center
25
286
Brigham and Women’s Faulkner Hospital
38
375
New England Baptist
6
64
Boston Medical Center
27
248
Beth Israel Deaconess Medical Center
56
599
Massachusetts General Hospital
74
732
Lower
CI
11.9
12.3
11.4
NA
12.2
10
10.2
Upper
CI
17.9
19.1
19.6
NA
18.8
14.9
14.8
US
Rate
15.2
15.2
15.2
15.2
15.2
15.2
15.2
Lower
CI
6.7
6.6
8.1
7.2
6.4
7.7
8.8
Upper
CI
10.1
11.4
13.5
14.4
10.5
11
12
US
Rate
11.7
11.7
11.7
11.7
11.7
11.7
11.7
Lower
CI
8.9
6.4
8
7
8.3
7.8
8.4
Upper
CI
13.2
11.2
13.1
14.6
14.4
11.4
12.1
US
Rate
11.9
11.9
11.9
11.9
11.9
11.9
11.9
11. __________________________ is better than the US for all three conditions.
5
Compare
to US
rate
Compare
to US
rate
Compare
to US
rate
12. See Exhibit E.7. Please fill in values for highlighted columns
Exhibit E.7 30-Day Readmissions
Acute Myocardial Infarction
30-day re#Case admission Lower
Hospitals
#Die
s
Rate
CI
Brigham and Women’s Hospital
114
548
18.3
Tufts Medical Center
87
438
17.1
Brigham and Women’s Faulkner Hospital
NA
22
NA
New England Baptist
NA
5
NA
Boston Medical Center
33
215
12.2
Beth Israel Deaconess Medical Center
135
657
18.3
Massachusetts General Hospital
150
805
16.4
Congestive Heart Failure
30-day re#Case
admission Lower
Hospitals
#Die
s
Rate
CI
Brigham and Women’s Hospital
214
931
20.8
Tufts Medical Center
110
443
21.8
Brigham and Women’s Faulkner Hospital
84
344
21.3
New England Baptist
15
65
18.4
Boston Medical Center
164
685
21.2
Beth Israel Deaconess Medical Center
289 1,166
22.7
Massachusetts General Hospital
304 1,298
21.3
Pneumonia
30-day re#Case
admission Lower
Hospitals
#Die
s
Rate
CI
Brigham and Women’s Hospital
86
482
15.4
Tufts Medical Center
73
358
17.4
Brigham and Women’s Faulkner Hospital
84
411
17.3
New England Baptist
11
64
14.2
Boston Medical Center
53
281
15.9
Beth Israel Deaconess Medical Center
130
713
16.2
Massachusetts General Hospital
155
781
17.6
Upper
CI
23.6
23
NA
NA
18.8
23.1
20.8
US
Rate
18.3
18.3
18.3
18.3
18.3
18.3
18.3
Upper
CI
25.5
28.1
28.1
27.5
26.7
27.1
25.6
US
Rate
23
23
23
23
23
23
23
Upper
CI
20.5
23.6
23.7
22
22.2
20.8
22.3
US
Rate
17.6
17.6
17.6
17.6
17.6
17.6
17.6
13. When comparing the seven hospitals to the Us rate …________________
6
Compare
to Us
Rate
Compare
to US
Rate
Compare
to US
rate
14. See Exhibit E.8. – Please fill in values in for highlighted column
Exhibit E.8. Patient Safety Indicators
Death from Serious Treatable Complications After Surgery
Hospitals
#
rate
Lower CI Higher CI
Brigham and Women’s Hospital
652
94.05
75.14
112.96
Tufts Medical Center
277 100.42
73.52
127.32
Brigham and Women’s Faulkner Hospital
22
NA
NA
NA
New England Baptist
82
94.95
46.42
143.48
Boston Medical Center
167 121.33
87.85
154.82
Beth Israel Deaconess Medical Center
327
99.89
74.94
124.84
Massachusetts General Hospital
765 111.72
95.13
128.31
Collapsed Lung Due to Medical Treatment
Hospitals
#
rate
Lower CI Higher CI
Brigham and Women’s Hospital
21,942
0.48
0.29
0.67
Tufts Medical Center
10,285
0.16
0
0.42
Brigham and Women’s Faulkner Hospital 5,595
0.45
0.09
0.81
New England Baptist
5,556
0.3
0
0.67
Boston Medical Center
12,963
0.23
0
0.49
Beth Israel Deaconess Medical Center
21,483
0.68
0.46
0.89
Massachusetts General Hospital
28,350
0.55
0.37
0.73
Serious Blood Clots After Surgery
Hospitals
#
rate
Lower CI Higher CI
Brigham and Women’s Hospital
11,703 6.04
5.09
7
Tufts Medical Center
4,036
4.91
3.22
6.59
Brigham and Women’s Faulkner Hospital
1,032
3.67
0.26
7.07
New England Baptist
5,057
2.11
0.37
3.84
Boston Medical Center
3,613
4.87
2.95
6.78
Beth Israel Deaconess Medical Center
7,696
4.27
3
5.55
Massachusetts General Hospital
13,003 4.69
3.8
5.58
A Wound That Splits Open
Hospitals
#
rate
Lower CI Higher CI
Brigham and Women’s Hospital
1,818
1.22
0.35
2.09
Tufts Medical Center
341
0.42
0
1.98
Brigham and Women’s Faulkner Hospital
176
1.39
0
3.22
New England Baptist
58
0.73
0
2.79
Boston Medical Center
420
1.44
0
2.93
Beth Israel Deaconess Medical Center
1,131
0.45
0
1.5
Massachusetts General Hospital
1,858
0.66
0
1.52
Accidental Cuts and Tears
Hospitals
#
rate
Lower CI Higher CI
Brigham and Women’s Hospital
25,432 2.12
1.66
2.58
Tufts Medical Center
11,221 2.4
1.56
3.23
Brigham and Women’s Faulkner Hospital
5,739
1.7
0.32
3.09
New England Baptist
4,862
1.29
0
2.89
Boston Medical Center
13,583 3.61
2.77
4.46
Beth Israel Deaconess Medical Center
23,046 3.15
2.59
3.72
Massachusetts General Hospital
30,802 1.69
1.25
2.14
7
US rate
110.15
110.15
110.15
110.15
110.15
110.15
110.15
Compare to US
US rate
0.32
0.32
0.32
0.32
0.32
0.32
0.32
Compare to US
US rate
4.14
4.14
4.14
4.14
4.14
4.14
4.14
Compare to US
US rate
0.92
0.92
0.92
0.92
0.92
0.92
0.92
Compare to US
US rate
1.83
1.83
1.83
1.83
1.83
1.83
1.83
Compare to US
15. See Exhibit E.9 Fill in values for highlighted columns (see last row before attempting)
Exhibit E.9. Summary of Quality Measures
Struct
Process2
Infections3
1
Exhibit E.2 –
Use bottom row to indicate how rates compare to US rates
ure
count
how many
from
measure
Exhibit
better / same
E.1
than state of
Mortality3
Readmissions3
Patient Safety Indicators3
Use bottom row to indicate how
Use bottom row to indicate how
Use bottom row to indicate how rates
rates compare to US rates
rates compare to US rates
compare to US rates
Exhibit E6,
Exhibit E.7
Exhibit E8
Exhibits E.3, E.4, E5
US
>M
ass
>
U
S
CLA
BSI –
Ex.
E3
(Cent
ral
Line
…
CAU
TI –
Ex E3
(Cathe
terAssoc
iatd
Colo
n–
Ex
E4
(Colo
n
Surg
ery)
Hyster –
Ex E4
(Abdomi
nal
Hysterec
tomy
MR
SA
– Ex
E5 (
CDIFF
– Ex
E5Clostri
dium
A
MI
Ex
E6
Ac
ute
..
CHF –
Ex E6
–
Conge
stive
…
Pneu=
Ex E6
Pneum
onia
A
MI
–
Ex
E7
–
Ac
ute
…
CHF –
Ex E7
–
Conge
stive
…
Pneu
Ex E7
Pneum
onia
Cmpl
– Ex
E8 –
Treat
able
…
Lu
ng
clo
ts
B+
W
Tuf
ts
Fau
lk
NE
B
B
M
C
Bet
h
M
GH
1=# structure measures; 2=# process measures better than either Massachusetts or United States; 3=better(+), worse(-) or the same (0) as US norms
8
Wou
nd
cu
ts
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