Background: To test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital. Methods: The ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post- intervention groups were followed up across the continuum of care for a period of 12 months. Results: VC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs). Conclusion: The implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and interdisciplinary collaboration within the organization through the program. There is potential for testing this methodology as a quality improvement framework replicable to other disease groups in a functionally integrated healthcare system. Keywords: Value-based care, Population health, Hip fracture, Singapore, Evidence-based medicine, ValuedCare, Integrated care, Care pathways * Correspondence: Chikul_mittal@cgh.com.sg; Mittal.email@example.com Clinical Services, Level 2, Changi General Hospital, 2 Simei Avenue 3, Singapore 529889, Singapore Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 2 of 10 Background Methods Hip fractures cause significant morbidity and mortality Setting in the elderly. Although the mainstay of treatment is Changi General Hospital (CGH) is a 1000-bed tertiary surgical fixation or replacement, these patients are acute hospital (AH) located in eastern Singapore. It is often vulnerable with complex medical, functional, psy- part of an Integrated Regional Health System (Eastern chosocial issues requiring a multidisciplinary approach Health Alliance) with formal partnerships and a range to maximize their recovery [1–7]. of healthcare organizations which have a specific focus Singapore is one of the most rapidly aging countries along the healthcare continuum. St. Andrews Commu- in Asia. The prevalence of adults older than 65 years is nity Hospital (SACH) is one of such partners with a set to rise from 9.9% in 2012 to about 20% in the next shared purpose of providing seamless integrated care 20 years [8, 9]. The International Osteoporosis Founda- for eastern Singapore . tion’s 2009 Asian Audit Report states that the incidence of hip fractures in Singapore is expected to increase The ValuedCare methodology from 1300 in 1998 to 9000 per annum by 2050 [9, 10]. Langley et al.  had shown quality improvement Singapore enjoys a unique healthcare ecosystem, where through process redesign, and Nolan et al. intro- acute episodic care is largely delivered at acute duced the concept of high reliability within healthcare. hospitals [AHs (tertiary care corporatized hospitals, Geisinger’s ProvenCare®  had successfully combined fully owned by the government)], while community both approaches to help address the gap between rec- hospitals (CHs) play an important role in the post- ommendations and actual clinical practice. In 2014, the acute rehabilitative care for elderly patients, particularly ValuedCare (VC) Hip Fracture Program was launched those with comorbidities. Therefore, the main functions as an ongoing collaboration between the Geisinger of the community hospitals are to provide geriatric Health System (GHS), USA, and Changi General Hos- assessment and rehabilitation and ongoing continuation pital, Singapore; modelled after the GHS ProvenCare® of medical or nursing treatment (sub-acute care) . Fragile Hip Fracture Program [14–21]. AH and CH could be independent or vertically The VC Hip Fracture Program was developed in three integrated co-located organizations with varying distinct phases: degrees of functional or normative integration based on geographical proximities. Care gap analysis; AH and CH, together with long-term care facilities Process redesign; and community care resources as well as primary care, Execution: implementation, capability building, aim to work together as a Regional Health System monitoring of compliance and evaluation. (RHS) to provide seamless integrated care [11–13]. The success of care pathways for hip fractures has Care gap analysis been variable . In spite of existing inpatient Facilitated discussions of internationally published pathways for patients admitted with hip fractures in evidence and local practice were essential in achieving Singapore AHs, there are inter- and intra-hospital physician consensus and translating recommendations variations in the level of coordination between different into local clinical application. To facilitate change man- clinical teams (e.g. geriatricians, orthopaedics, anaes- agement in a multidisciplinary team, clinical champions thetists, emergency physicians, case managers and (senior clinicians and domain experts) were appointed therapists), length of stay, time to surgery and bill sizes, from stakeholder departments including orthopaedics, often causing fragmentation of care. Additionally, most geriatrics, case management, nursing, allied health and reported studies take into account only the AH admis- emergency medicine as well as anesthesiology. Clinical sions. There is a paucity of data on the effectiveness/ champions were actively involved in appraising the long-term outcomes of hip fracture programs across evidence together. Level I and II evidence were chosen the entire care continuum. and discussed, to select 23 best practice elements Thus, our aim was to create and test a population (BPEs) across the care continuum. Figure 1 summarizes health program which could, through the application of the 23 BPEs; operational definitions and measurable process redesign, implement multiple evidence-based elements were defined for each of the BPEs to ensure medical practices across the continuum of care in an compliance. integrated delivery system and deliver highly reliable and consistent evidence-based care for episodic surgical Process redesign interventions. Our process redesign began with the fundamental Ethical clearance was obtained by the Institutional principle of designing and delivering patient-centric Review Board (IRB) for this study. care consistently across the entire care continuum. A Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 3 of 10 Fig. 1 ValuedCare 23 best practices from A&E to inpatient stay and post-discharge care multidisciplinary team led by the clinical champions Execution worked together to hardwire the evidence-based BPEs Quality improvement and governance components into clinical workflows, prevent duplication of services were deliberately added into the program structure to and variability of care, and to manage the health of this assure compliance to each of the process elements. All patient population, since many of them have multiple participants knew that compliance with each of the co-morbidities. Our intent was to further encourage a processelements, both asa team andasindividuals, productive interaction between informed, activated would be tracked and real-time feedback given. Due to patients and prepared proactive staff. The team studied the strong measurement strategy, any process defect current process flows for each discipline and utilized was quickly identified and a focused redesign was value stream mapping to visualize how multiple disci- immediately started. plines should interact in an integrated pathway. For clinical governance, a clinical core team was The finalized care pathway and BPEs were hardwired created to lead the redesign of the care process and using information technology and electronic health implementation of reliable evidence-based care. The records (EHR) to enable behavior change and provide multidisciplinary clinical core team monitored compli- decision support, as well as facilitate ease of informa- ance to BPEs, information diffusion to ground staff and tion diffusion across multiple settings. The aim was to issues faced on the ground. This team was also respon- make best care fall within the path of least resistance sible for the ownership of clinical outcomes. and in-build a system to minimize unwarranted varia- The team conducted continuous quality improvement tions in care. (QI) focus biweekly meetings, where members from dif- The care process entailed visualizing the patient jour- ferent disciplines voice out issues faced on the ground ney starting from presentation at the accident and andbrainstormedto findsolutions andbuildconsensus emergency department (A&E), acute hospital admis- for immediate remedy or proposed plans for action to sion, community hospital admission and care transition address deficiencies in care processes or health out- into the community as well as post-discharge specialty comes. These meetings worked as mini-PDSA (Plan- care to assess long-term functional outcomes and start Do-Study-Act) cycles and spearheaded the short-term secondary prevention. quality improvements within the program. Table 1 Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 4 of 10 Table 1 Key process improvements achieved through ValuedCare methodology Objectives Pre-intervention Post-intervention Early surgery within Anaesthetic guidelines appended in pathway not used Orthopaedic team identifies and lists patients for early 48 h routinely surgery with the use of anaesthetic checklist upon clerking Investigations ordered by the accident and emergency A&E doctor commences investigation order set to facilitate department (A&E) and the orthopaedics team, resulting orthopaedics team in review and listing for surgery in missing or duplicate orders Delayed review of early surgery rates 2 weekly multi-disciplinary review of early surgery rates and documentation of reasons for delayed surgery No dedicated high dependency (HD) beds for 3 dedicated HD beds for ValuedCare patients post-operative care, causing surgical delays Reduce DVT prophylaxis starts from ward admission DVT prophylaxis starts from A&E complications Ad hoc prescribing of pain, bowel medications, Standardized electronic orders used by orthopaedics team supplements and antibiotics Medications reviewed by ortho-geriatrician and pharmacist Restore patient’s (Post-operative day 1) POD 1 mobilisation by POD 1 mobilisation by physiotherapist actively tracked and functional ability to physiotherapist not tightly enforced enforced pre-fracture state Patient outcome measures acquired only from Expanded patient outcome measures acquired from both inpatient, inpatient stay outpatient clinic and community hospital over 1 year post-surgery Enhanced Manual workflow in documentation with Electronic documentation in organizational electronic medical record information flow subsequent transcribing to electronic (EMR) system and collection Real-time best practice elements compliance dashboard summarizes the key improvements achieved as a result (metastasis, avascular necrosis) were excluded from the of discussions with clinical core team and PDSA cycles. study. The program office provided administrative govern- ance in collaboration with clinical core teams, in order Objective to establish and implement processes to improve care To compare clinical outcomes, complications and health- and reduce variation. The program office also facilitated care utilization between baseline and ValuedCare groups. implementation work by addressing barriers and apply- ing quality improvement techniques, which included the Statistical analysis development and implementation of appropriate clinical Descriptive epidemiology was used to present demo- data collection tools, as well as EHR tool build-up and graphic variables. Medians were compared using implementation. It was also responsible for planning and Kruskal-Wallis/Mann-Whitney U test. Categorical vari- implementing the scaling up and spread of the Valued- ables were compared using chi-square test and interval Care model in AH and CH. variables using analysis of variance (ANOVA). Statistical For the strategic support, an oversight/steering com- calculations were performed using Stata 12. mittee was created including senior management from both and CH. This platform was useful to review and Results provide on-going feedback on the progress of the VC The demographic variables and baseline characteristics program, and also for ‘buy-in’, as senior management between pre-intervention and VC patients are reported from different organizations could come together to in Table 2. The two groups had comparable representa- share concerns and chart directions. The oversight/steer- tions in age, gender, race, pre-fracture residence and ing committee also improved the functional integration pre-fracture mobility. between inter-hospital team members. Table 3 compares outcomes between baseline pre- intervention and VC populations. The inpatient, 30-day Study design post-discharge and 12-month post-discharge mortality Non-randomized historical controlled study for patients remained low at 1.2, 1.2 and 8% respectively; mortality aged 65 years and above treated for single and low- data was obtained from a national registry. Forty-eight energy hip fractures and undergone hip fracture surgery percent of the VC patients received surgical treatment at AH. A baseline pre-intervention cohort was selected within 48 h from admission, compared to 18.8% at base- with admission dates between 1 January 2013 to 31 line. Median time to surgery was reduced from 97 to 50. December 2013 (n = 351), while the VC cohort com- 5 h. Early access to surgery has shown to improve clin- prised of patient admissions between 1 December 2014 ical outcomes in several international studies [5, 10]. VC to 30 November 2015 (n = 329). Patients with multiple patients also had less acute inpatient complications as fractures, high-impact trauma and pathological fractures compared to the baseline pre-intervention cohort, in Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 5 of 10 Table 2 Demographics and pre-morbidity profile baseline and ValuedCare groups Variable Baseline (n = 351) ValuedCare (n = 329) p value Age Mean (SD) 81.11 (8.0) 80.35 (7.4) 0.20 Median (min–max) 82 (65–99) 81 (65–102) 0.85 Age group, n (%) 0.013 65–74 91 (25.9%) 78 (23.7%) 75–84 130 (37.0%) 157 (47.7%) ≥ 85 130 (37.0%) 94 (28.6%) Gender, n (%) 0.617 Females 247 (70.4%) 225 (68.4%) Males 104 (29.6%) 104 (31.6%) Race, n (%) 0.557 Chinese 265 (75.5%) 247 (75.1%) Malays 49 (14.0%) 51 (15.5%) Indians 20 (5.7%) 12 (3.6%) Others 17 (4.8%) 19 (5.8%) Pre-fracture residence, n (%) 0.77 Home 332 (94.6%) 312 (94.8%) Nursing home 14 (4%) 12 (3.6%) Sheltered home 5 (1.4%) 5 (1.5%) Pre-fracture aid, n (%) 0.152 No aid 187 (53.3%) 197 (61%) Walking aid 157 (44.7%) 118 (36.5%) Wheelchair 7 (2%) 6 (1.9%) Bedbound 0 1 (0.3%) Others 0 1 (0.3%) Hypertension 188 (53.6%) 228 (69.3%) < 0.001 Hyperlipidaemia 99 (28.2%) 145 (44.1%) < 0.001 Diabetes mellitus 130 (37.0%) 111 (33.7%) 0.379 Ischaemic heart disease (IHD) 68 (19.4%) 51 (15.5%) 0.191 CCF/heart failure 11 (3.1%) 12 (3.6%) 0.83 COPD/cold/asthma 15 (4.3%) 17 (5.2%) 0.593 Peripheral vascular disease (PVD) 13 (3.7%) 5 (1.5%) 0.095 Chronic renal failure 50 (14.2%) 23 (7.0%) 0.03 particular lower rates of delirium, pneumonia, urinary p value < 0.001. Figure 2 also shows a decreasing trend tract infections (UTI) and pressure sores. A reduction in in AH monthly average LOS for a 1-year post- 30-day and 180-day readmission rates for hip fracture- intervention period (p value < 0.001, R = 0.452) and a related causes was noticed, although not statistically corresponding increasing trend for a percentage of significant. patients with LOS ≤ 10 days (p value < 0.001, R = 0.522). Comparisons of length of stay (LOS) between pre- and Implementation of VC in CH began 1 year later than post-intervention data at AH and AH-CH combined are that in AH; thus, pre- and post-intervention data for summarized, respectively, in Figs. 2 and 3. A LOS of combined LOS were studied a year later as compared to ≤ 10 days for AH was taken as an internal reference tar- AH data (Fig. 3). There was a significant reduction in get at the beginning of the program after a review of combined LOS (AH + CH) between baseline and post- relevant literature [3, 22]. For AH (Fig. 2), the reduction intervention population values (p value < 0.001). A in LOS was noticed to be statistically significant at a decreasing trend in monthly average LOS for a 1-year Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 6 of 10 Table 3 Comparison of clinical outcomes between baseline and ValuedCare patients Mortality rates Variable Baseline (n = 351) ValuedCare (n = 329) p value Index inpatient mortality, n (%) 6 (1.7%) 4 (1.2%) 0.75 Variable Baseline (n = 344*) ValuedCare (n = 325*) p value Post-discharge 30 days mortality rate, n (%) 1 (0.3%) 4 (1.2%) 0.2 Post-discharge 12 months mortality rate, n (%) 27 (7.8%) 26 (8.0%) 0.94 Acute hospital inpatient complications Variable Baseline (n = 351) ValuedCare (n = 329) p value Wound infection 1 (0.3%) 0 (0.0%) 0.5136 Implant failure 4 (1.1%) 1 (0.3%) 0.374 Delirium 36 (10.3%) 13 (4.0%) 0.002 Acute retention of urine (ARU) 53 (15.1%) 34 (10.3%) 0.067 Pneumonia 45 (12.8%) 13 (4.0%) < 0.001 Urinary tract infection (UTI) 90 (25.6%) 16 (4.9%) < 0.001 Pressure sore 39 (11.1%) 1 (0.3%) < 0.001 Deep vein thrombosis 4 (1.1%) 8 (2.4%) 0.250 Pulmonary embolism 5 (1.4%) 2 (0.6%) 0.452 Acute myocardial infarction 8 (2.3%) 5 (1.5%) 0.580 Stroke 4 (1.1%) 2 (0.6%) 0.687 Readmission rates Baseline (n = 344*) ValuedCare (n = 325*) 30-day readmission (all cause), n (%) 26 (7.6%) 31 (9.5%) 0.36 30-day readmission (hip fracture related), n (%) 17 (4.9%) 12 (3.7%) 0.42 180-day readmission (all cause), n (%) 74(21.5%) 72 (22.2%) 0.84 180-day readmission (hip fracture related), n (%) 44 (12.8%) 27 (8.3%) 0.06 Time to surgery Baseline (n = 351) ValuedCare (n = 329) Surgery within 48 h from time of decision to admit 66 (18.8%) 158 (48.0%) < 0.001 Time to surgery, h < 0.001 Mean (SD) 119.2 (86.3) 70.63 (64.4) Median (min–max) 97 (11–499) 50.5 (0.11–638) *Inpatient deaths and discharge against advice cases are taken out of the analysis post-intervention period (p value < 0.001, R = 0.32) was just hospital-based services), so that true efficiencies are also noticed. achieved to create value for patients (e.g. right siting of services and elimination of non-value adding services). Discussion VC BPEs include preventive interventions such as osteo- As Michael Porter describes, value cannot be understood porosis treatment, secondary fall prevention, functional at the level of a hospital, a care site, a specialty, or an rehabilitation and caregiver training. It also measures intervention. Value is created in caring for a patient’s longer term functional health outcomes such as longitu- medical condition over the full cycle of care . VC dinal Modified Barthel’s Index (MBI)/Barthel and Func- program attempts to implement system level transform- tional Independence. ation to measure health outcomes over disease life cycle, We compared the results of our VC program with the including functional outcomes, and cost of care over published results of international Geriatric Fracture care continuum across institutions. The focus thus shifts Centers (GFCs) in terms of LOS, mortality and morbid- to providing evidence-based and consistent patient care ity data (Table 4). Among the models compared, Valued- to achieve better outcomes over the entire cycle of care, Care’s mortality rates of 1.2 and 8% were the lowest for, instead of merely introducing cost containment mea- respectively, intra-hospital rates and at 1 year follow-up. sures within a particular institution. VC program aims One-year mortality for surgically managed hip fracture to totally study the overall healthcare ecosystem (rather cases has been reported in some overseas centres to be Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 7 of 10 Fig. 2 Length of stay (acute hospital) as high as 30% . Our 30-day readmission rates are LOS (AH + CH), has shown consistent significant im- also among the lowest. It was noticed in the inter- provement. ALOS at AH decreased from 16.3 to 12. national literature that LOS can vary between 4.2 and 3 days (median 13 to 9 days), while combined ALOS 15.8 days. Several factors affect LOS, such as differences (AH + CH) showed a reduction from 51.6 to 43.3 days in models of step-down care available in different coun- (median 46 to 39 days). Reduction in combined length tries, efficiency of referral mechanisms, level of integra- of stay is of relevant importance as it indicates that this tion, as well as availability of step-down or rehabilitation result was achieved with process redesign instead of care beds. In Rochester , where the LOS is the short- shifting the burden of care to the next healthcare setting. est (4.2 days), patients are moved to their nursing facility Reductions in LOS, along with reduction in hip fracture- rehabilitation beds by the third post-operative days. In related admissions up to 6 months (12.8 to 8.3%), result most centres, including Singapore, patients have to wait in savings in hospital bed days. This is significant espe- for an available bed in rehabilitation hospital or CH. cially in the context of rising demand for hospital beds Under the VC program, AH and CH teams worked and costs with a growing ageing population. together to streamline the inter-hospital transfer process In both AH and CH, rehabilitation doctors, nurses, and eliminate unnecessary administrative steps. Referral therapists and medical social workers work together to requests were raised early (post-operative day 2), and speed up the recovery process. Early active walking exer- specific referral and acceptance criteria were delineated cise and post-discharge rehabilitation by community and made transparent to the clinical team. CH rehabili- nurses and therapists play an important role in shorten- tation team reviewed the patient at AH and hastened ing the need for inpatient treatment. The regular assess- the transfer process if patients met the predefined ments of the mental and functional state can help to criteria. enhance the recovery of patients. The medical social It was noticed that after VC implementation, the aver- workers identify social or financial problems that may age length of stay (ALOS) at AH, as well as combined complicate the discharge and activate available resources Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 8 of 10 Fig. 3 Combined length of stay (AH + CH). Combined average LOS distribution in days to help them. The overall shortened hospital stay reflects Conclusion the effectiveness and cooperation with this multidiscip- The implementation of VC hip fracture program has linary approach. enabled consistent delivery of high-quality, reliable and VC results are consistent with our hypothesis that with comprehensive evidence-based care for hip fracture implementation of BPEs and minimizing unwarranted patients. This has been further strengthened by success- variations in care, health and utilization outcomes can be ful change management and interdisciplinary collabor- improved. The team acknowledges the scope for further ation within the organization. Efforts are on-going to improvements in the combined LOS in AH + CH. We are sustain these best practices and augment gains. The working towards achieving our target of getting at least program will be scaled to include other medical condi- 70% VC cases operated within 48 h from hospital tions using VC methodology which could, through the admission. Also, detailed analysis of functional outcomes, application of process redesign, implement multiple quality of life (QOL) and interventions for secondary pre- evidence-based medical practices across the continuum vention of falls and fractures will be performed within the of care in an integrated delivery system and deliver high- next phase of VC program. quality reliable care. Table 4 Comparison of length of stay, morbidity and mortality data of various geriatric hip fracture programs [8, 23–26] Rochester model Innsbruck model Singapore Hong Kong National Hip Fracture   ValuedCare model  Database (UK) [8, 22] Length of stay, days 4.2 11.3 9 6.4 15.8 30-day readmission 9.8 5.2 3.7 15 11.8 Hospital mortality rates, % 1.6 3.1 1.2 1.25 8.2 1-year mortality, % 21.2 Not available 8 16.4–22.4 19.3 Mittal et al. Journal of Orthopaedic Surgery and Research (2018) 13:129 Page 9 of 10 Limitations Community Hospital, Singapore, Singapore. Medical Services, St. Andrews Community Hospital, Singapore, Singapore. Health Services Research, Non-randomized historical controlled study design has Changi General Hospital, Singapore, Singapore. Executive Office, Changi inherent limitations, but a randomized control trial pre- General Hospital, Singapore, Singapore. sents ethical concerns as the ‘intervention’ aim consists of Received: 11 December 2017 Accepted: 24 April 2018 implementing best practice elements. The implementation of VC program in CH was a year later as compared to that in AH; thus, pre- and post-intervention data for CH LOS References was studied a year later as compared to AH data. Re- 1. Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and admission data were specific to AH as we do not have data disability associated with hip fracture. Osteoporos Int. 2004;15:897–902. 2. Grigoryan KV, Javedan H, Rudolph JL. Orthogeriatric care models and for readmissions to other hospitals. outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014;28:49–55. Abbreviations 3. National Institute for Health and Care Excellence. 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Langley GL, Nolan KM, Nolan TW, et al. The improvement guide: a EG were involved in the manuscript revision. EL provided supervision as well practical approach to enhancing organizational performance. San as overall strategic direction for the study and VC program. LS performed the Francisco: Jossey-Bass; 1996. statistical analysis for the study. All authors read and approved the final 15. Nolan TN, Resar R, Haraden C, et al. Improving the reliability of health care. manuscript. Innovation series white paper. Cambridge: Institute of Health Improvement; 2004. 16. Berry SA, Doll MC, et al. ProvenCare: quality improvement model for Ethics approval and consent to participate designing highly reliable care in cardiac surgery. Qual Saf Health Care. The audit and secondary analysis of this dataset was in keeping with 2009;18:360–8. national guidelines as stipulated by Singapore Ministry of Health under 17. Slotkin JR, Casale AS, et al. 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Journal of Orthopaedic Surgery and Research – Springer Journals
Published: May 30, 2018
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