Patient safety culture and associated factors among health care providers in government and private hospitals, Bahir Dar City Northwest, Ethiopia, 2022: a comparative cross-sectional study.

BACKGROUND: Patient safety in a healthcare setting is now a major global concern. Millions of people suffer disabling injuries or death directly related to medical care errors, particularly in developing countries. Evidence about patient safety culture in Ethiopia is limited. Therefore, this study was designed to assess the level of patient safety culture and associated factors among healthcare providers in government and private healthcare providers. METHODS AND MATERIALS: Institution based cross-sectional study was conducted from May to June 30, 2022. Self-administered hospital survey on Patient Safety Culture (HSOPSC) tool was used to select 448 study participants. Epi Data version 4.6 and SPSS version 26 were used for data entry and analysis. Chi-square test, Bi-variable, and multivariable logistic regressions were done to determine the association between the independent and outcome variable. RESULT: A total of 448 healthcare providers with a response rate of 99.6% participated. The prevalence of good patient safety culture was 50.9%( 95%CI: 46.2, 55.6%). Patient safety culture difference was observed between government and private healthcare providers (× 2 = 22.6, df = 1, p = 0.000). Type of hospitals (AOR = 0.37(95% CI:(0.21, 0.68), profession (AOR = 2.16 (95% CI:(1.02,4.62), job satisfaction (AOR = 0.19,95%CI:(0.12,0.30), participated in patient safety programs(AOR = 2.69:(95%CI:1.53,4.75), providing necessary equipment and materials (AOR = 2.05(95%CI: 1.18,3.55%), and work shift (AOR = 0.47( 95%CI: 0.25,0.93) were found significantly associated with good patient safety culture among healthcare providers. CONCLUSION: The prevalence of good patient safety culture was relatively low. Patient safety culture difference is observed between government and private healthcare providers. Type of hospitals (public or private), profession, job satisfaction, participation in patient safety programs, providing necessary equipment and materials, and work shifts were associated factors for patient safety culture. Therefore, it is better to design patient safety improvement strategies for both government and private healthcare providers.

Knowledge and Practice about Glasgow Coma Scale Assessment among Nurses Working in Adult Intensive Care Units of Federal Public Hospitals in Addis Ababa, Ethiopia: A Cross-Sectional Study.

Background: The Glasgow Coma Scale is a dependable and objective neurological assessment instrument used for determining and recording a patient's level of consciousness. Therefore, the knowledge, practice, and factors affecting Glasgow coma scale evaluation among nurses working in adult intensive care units of federally administered hospitals in Addis Ababa, Ethiopia, were investigated. Methods: From April 4 to 24, 2020, 121 Adult Intensive Care Unit nurses at Ethiopian federal hospitals participated in an institutional-based cross-sectional survey with a standardized self-administered questionnaire. The information was entered into Epidata version 3.1 and then exported to SPSS version 25.0 for analysis. Bivariable and multivariable logistic regressions were used to examine the relationships between independent and dependent variables. Result: According to this study, nurses working in the Adult Intensive Care Unit of federal hospitals in Addis Ababa, Ethiopia, had poor knowledge (51.2%) and poor practice (62%) of the Glasgow Coma Scale's basic theoretical notions and competencies. Furthermore, the education and gender of nurses were linked to their level of knowledge and clinical practice. Being a male and having a master's degree were both significantly linked with knowledge(AOR = 4.13, 95% CI: (1.87-9.1)), (AOR=7.4, 95% CI: (1.4-38)) and practice (AOR = 2.7, 95% CI: (1.2-6)), (AOR = 10.4, 95% CI: (2.0-53)) respectively. Conclusion: The findings from this study showed that nurses had poor knowledge and application of practice-related clinical scenarios on the Glasgow Coma Scale.

Magnitude of job satisfaction and intention to leave their present job among nurses in selected federal hospitals in Addis Ababa, Ethiopia.

BACKGROUND: Job dissatisfaction issues and health workers' intention to leave is an increasing problem that threatens the function of the health care sector worldwide, especially in developing countries, including Ethiopia. As part of future evidence, this study was intended to assess nurses' job satisfaction and intention to leave their current work and its associated factors in federal public hospitals in Addis Ababa, Ethiopia. METHOD: An institutional based cross-sectional study design was used to conduct the study. A simple random sampling technique was employed to select 408 nurses from selected federal hospitals in Ethiopia. Self-administered questionnaire was used to collect the data. Logistic regression was employed to identify the predictor variables with consideration of statistical significance at P <0.05 adjusted odds ratios calculated at 95% CIs. RESULT: The magnitudes of job satisfaction and intention to leave their current job among nurses in this study were 47.7% and 80.6%, respectively. Salary is imbalanced with demands [AOR = 2.85 (1.24, 6.57)], managers who have no personal plan for developing skills [AOR = 3.74 (1.58, 8.87)], stressful jobs [AOR = 0.28 (0.11, 0.71)], health problems are a reason for having thoughts about changing jobs [AOR = 3.02 (1.17, 7.79)], and a lack of development [AOR = 4.13 (1.51, 11.3)] were identified as determinant factors for intention to leave. CONCLUSION: The overall intention to leave their current job among nurses working in selected federal hospitals in Ethiopia was high. The government of Ethiopia should balance the salary of nurses with the current market level. Hospital leaders should plan the way nurses develop their educational and job carrier levels.

Medication administration errors and associated factors among nurses in Addis Ababa federal hospitals, Ethiopia: a hospital-based cross-sectional study.

OBJECTIVE: This study was conducted to assess the magnitude and contributing factors of medication administration errors among nurses in federal hospitals in Addis Ababa, Ethiopia. DESIGN: A hospital-based cross-sectional study design was employed. Data on medication administration and associated factors were collected using a structured self-administered questionnaire. Multivariable binary logistic regression analysis was done to identify factors associated with medication administration errors on the basis of adjusted OR with 95% CI and a p value less than 0.05. SETTING: This study was conducted in federal hospitals in Addis Ababa, Ethiopia. PARTICIPANTS: Four hundred and twenty-three randomly selected nurses participated. OUTCOME MEASURES: The primary outcome variable is medication administration error, which was ascertained using the following errors: wrong medication, wrong dose, wrong time, wrong route, wrong patient, wrong drug preparation, wrong advice, wrong assessment and wrong documentations. RESULTS: A total of 59.9% (95% CI: 55.0% to 64.8%) of the nurses in the federal hospitals in Addis Ababa committed one or more medication administration errors in the last 12 months prior to the survey. The most commonly reported medication errors were wrong time (56.8%), wrong documentation (33.3%), wrong advice (27.8%) and wrong dose (20.1%). Medication administration errors among nurses were significantly associated with short work experience (adjusted OR (AOR): 6.48, 95% CI: 1.32 to 31.78), night shift work (AOR: 5.0, 95% CI: 1.82 to 13.78), absence of on-the-job training (AOR: 3.16, 95% CI: 1.67 to 6.00), unavailability of medication administration guidelines in wards (AOR: 2.07, 95% CI: 1.06 to 4.06) and interruptions during medication administration (AOR: 2.42, 95% CI: 1.30 to 4.49). CONCLUSION: It was found that a high proportion of nurses in federal hospitals committed medication administration errors. Short work experience, night shift work, absence of on-the-job training, unavailability of medication administration guidelines and interruptions during medication administration explained the high magnitude of medication administration errors.

Smoking and cessation behaviors in patients at federally funded health centers - United States, 2014.

BACKGROUND: Federally funded health centers (HCs) provide care to the most vulnerable populations in the U.S., including populations with disproportionately higher smoking prevalence such as those with lower incomes. METHODS: This study compared characteristics of adult HC patients, by cigarette smoking status, and assessed smoking cessation-related behaviors using 2014 Health Center Patient Survey data; analysis was restricted to adults with data on cigarette smoking status (n = 5583). Chi-square and logistic regression analyses were conducted. RESULTS: Overall, 28.1 % were current smokers and 19.2 % were former smokers. Current smokers were more likely to report fair/poor health (48.2 %) and a high burden of behavioral health conditions (e.g., severe psychological distress 23.9 %) versus former and never smokers. Most current smokers reported wanting to quit in the past 12 months (79.0 %) and receiving advice to quit from a healthcare professional (78.7 %). In a multivariable model, age <45, non-white race, COPD diagnosis, and past 3-month marijuana use were significantly associated with desire to quit. Few former smokers (15.2 %) reported using cessation treatment, though use was higher among those who quit within the previous year (30.6 %). CONCLUSIONS: Although most current smokers reported a desire to quit, low uptake of evidence-based treatment may reduce the number who attempt to quit and succeed. Given the burden of tobacco use, future efforts could focus on identifying and overcoming unique personal, healthcare professional, or health system barriers to connecting them with cessation treatments. Increasing access to cessation treatments within HCs could reduce smoking-related disparities and improve population health.

The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery.

The COVID-19 pandemic has altered mental health care delivery like no other event in modern history. The purpose of this study was to document the magnitude of that effect by examining (a) the amount of psychologists' telepsychology use before the COVID-19 pandemic, during the pandemic, and anticipated use after the pandemic; as well as (b) the demographic, training, policy, and clinical practice predictors of these changes. This study used a cross-sectional, national online design to recruit 2,619 licensed psychologists practicing in the United States. Prior to the COVID-19 pandemic, psychologists performed 7.07% of their clinical work with telepsychology, which increased 12-fold to 85.53% during the pandemic, with 67.32% of psychologists conducting all of their clinical work with telepsychology. Psychologists projected that they would perform 34.96% of their clinical work via telepsychology after the pandemic. Psychologists working in outpatient treatment facilities reported over a 26-fold increase in telepsychology use during the pandemic, while those in Veterans Affairs medical centers only reported a sevenfold increase. A larger increase in percentage telepsychology use occurred in women, in psychologists who reported an increase in telepsychology training and supportive organizational telepsychology policies, and in psychologists who treated relationship issues, anxiety, and women's issues. The lowest increases in percentage telepsychology use were reported by psychologists working in rural areas, treating antisocial personality disorder, performing testing and evaluation, and treating rehabilitation populations. Although there was a remarkable increase in telepsychology use during the COVID-19 pandemic, individual and practice characteristics affected psychologists' ability to adopt telepsychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

COVID-19: a cross-sectional study of suspected cases admitted to a federal hospital in Rio de Janeiro, Brazil, and factors associated with hospital death. / COVID-19: estudo seccional de casos suspeitos internados em um hospital federal do Rio de Janeiro e fatores associados ao óbito hospitalar.

OBJECTIVE: To describe the clinical and epidemiological profile of suspected COVID-19 cases admitted to a federal hospital in Rio de Janeiro, RJ, Brazil, and to identify factors associated with death. METHODS: This was a cross-sectional study using local epidemiological surveillance data as at epidemiological week 27 of 2020 and logistic regression. RESULTS: 376 hospitalized suspected COVID-19 cases were included; 52.9% were female, 57.4% were 50 years old or over and 80.1% had comorbidities. 195 (51.9%) COVID-19 cases were confirmed and their lethality was higher (37.9%) than among discarded cases (24.2%). In the adjusted analysis, death among confirmed cases was associated with being in the 50-69 age group (OR=11.65 - 95%CI 1.69;80.33), being aged 70 or over (OR=8.43 - 95%CI 1.22;58.14), presence of neoplasms (OR=4.34 - 95%CI 1.28;14.76) and use of invasive ventilatory support (OR=70.20 - 95%CI 19.09;258.19). CONCLUSION: High prevalence of comorbidities and lethality was found; the main factors associated with death were being older, neoplasms and invasive ventilatory support.

Implementing the Patient Health Questionnaire Modified for Adolescents to improve screening for depression among adolescents in a Federally Qualified Health Centre.

BACKGROUND: Depression, which is a serious medical illness, is prevalent worldwide and it negatively impacts the adolescent lifestyle. Adolescent depression is associated with adverse emotional and functional outcomes and suboptimal physical health. Over the last decade, it has been found that approximately 9% of teenagers meet the criteria for depression at any given time, and one in five teenagers have a history of depression during adolescence. Ninety per cent of paediatricians believe that recognition of child and adolescent depression is their responsibility; however, it has been reported that 46% lacked confidence that they could recognise depression. METHODS: In this study, adolescents between 12 and 17 years of age were screened during their well-child visits using the Patient Health Questionnaire Modified for Adolescents. A score of 10 or higher warrants a referral to a social worker and psychiatrist. The goals of this quality improvement project were to implement a standardised questionnaire and to improve the screening, diagnosis and treatment of depression in children from 12 to 17 years of age. RESULTS: It was found that the adolescent depression screening rate significantly improved within 6 months of implementing this quality improvement project. The screening rate improved to 50% by mid-cycle (Plan-Do-Study-Act (PDSA) cycle 3) and up to 70% at the end of the 6-month period (PDSA cycle 5). Improvement was noted among all providers, across all age groups, and in both male and female patients by the end of the study period. CONCLUSION: Standardised screening tests with a scoring system help providers to identify and monitor depression symptoms using a common language, especially in the outpatient clinical setting where the patient may be seen by different providers.

The Value Transformation Framework: An Approach to Value-Based Care in Federally Qualified Health Centers.

BACKGROUND: With the transition toward value-based care, health care organizations have a business imperative to simultaneously focus on improved health outcomes, improved patient and staff experience, and reduced costs (the Quadruple Aim). For federally qualified health centers-which provide care to some of nation's most vulnerable populations-balancing the complex task of systems change in the face of overwhelming volumes of information and best practices is challenging and can be supported through a guiding framework. PURPOSE: This need for synthesis and translation of evidence in an actionable and practical way led to the design of a model for health center systems change. This article describes the development process and defines the resulting conceptual framework. METHODS: Deployed a four-step process between 2016 and 2018 to develop and test a framework for value transformation in health centers. RESULTS: NACHC's Quality Center developed the Value Transformation Framework to guide health center systems change toward high value care. The framework identifies 15 change areas across three Domains: infrastructure, care delivery, and people and summarizes evidence-based action steps within the change areas. CONCLUSIONS: The framework shows promise in supporting health center efforts to adapt, transform, and balance competing demands as they advance value-based models of care.

Effect of antenatal counselling on early initiation of breastfeeding, an interventional study at two Federal Hospitals, Islamabad Pakistan.

OBJECTIVE: To determine the effect of antenatal counselling at term on early initiation of breastfeeding. METHODS: The prospective, questionnaire-based study was conducted at two state-run hospitals in Islamabad, Pakistan, from July to December 2016. One hundred subjects at the Federal General Hospital represented intervention group A and received special antenatal counselling regarding benefits of early initiation of breastfeeding, while 100 subjects at the Islamabad Polyclinic formed control group B and received routine counselling. Data was analysed using SPSS Version 20. RESULTS: Of the 200 subjects initially enrolled, 185 were included in the data analysis , 91 in the intervention group (A) and 94 among the control group (B) and Rest were excluded due to missing data. In group A, 46 (50.5%) women initiated breastfeeding within one hour of childbirth, while in group B 17 (18.08%) women did early inititation (p <0.001). CONCLUSION: Counselling was seen to be associated with early initiation of breastfeeding.

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

BACKGROUND: Federally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools. EXPERIENCE: There was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH. RECOMMENDATIONS: We make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs' Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.

Geographic Expansion of Federally Qualified Health Centers 2007-2014.

PURPOSE: Federally Qualified Health Centers (FQHCs), which were expanded under the Affordable Care Act, are federally funded health centers that aim to improve access to primary care in underserved areas. With continued federal support, the number of FQHCs in the United States has increased >80% within a decade. However, the expansion patterns and their impact on the population served are unknown. METHODS: A pre (2007)-post (2014) study of FQHC locations. FQHC locations were identified from the Provider of Services Files then linked to primary care service areas (PCSAs), which represent the service markets that FQHCs served. Road-based travel time was estimated from each 2007 FQHC to the nearest new FQHC as an indicator of geographic expansion in access. PCSA-level characteristics were used to compare 2007 and 2014 FQHC service markets. FINDINGS: Between 2007 and 2014, there was greater expansion in the number of FQHCs (3,489 vs 6,376; 82.7%) than in the number of service markets (1,835 vs 2,695; 46.9%). Nearly half of 2007 FQHCs (47%) had at least one new FQHC within 30 minutes travel time. Most newly certified FQHCs (81%) were located in urban areas. Compared to 2007 service markets, the new 2014 markets (N = 174) were much less likely to be in areas with >20% of the population below poverty (31.4% vs 14.9%, P < .001). CONCLUSIONS: The latest expansion of FQHCs was less likely to be in rural or high poverty areas, suggesting the impact of expansion may have limitations in improving access to care among the most financially disadvantaged populations.

Investigation of a Cluster of Sphingomonas koreensis Infections.

BACKGROUND: Plumbing systems are an infrequent but known reservoir for opportunistic microbial pathogens that can infect hospitalized patients. In 2016, a cluster of clinical sphingomonas infections prompted an investigation. METHODS: We performed whole-genome DNA sequencing on clinical isolates of multidrug-resistant Sphingomonas koreensis identified from 2006 through 2016 at the National Institutes of Health (NIH) Clinical Center. We cultured S. koreensis from the sinks in patient rooms and performed both whole-genome and shotgun metagenomic sequencing to identify a reservoir within the infrastructure of the hospital. These isolates were compared with clinical and environmental S. koreensis isolates obtained from other institutions. RESULTS: The investigation showed that two isolates of S. koreensis obtained from the six patients identified in the 2016 cluster were unrelated, but four isolates shared more than 99.92% genetic similarity and were resistant to multiple antibiotic agents. Retrospective analysis of banked clinical isolates of sphingomonas from the NIH Clinical Center revealed the intermittent recovery of a clonal strain over the past decade. Unique single-nucleotide variants identified in strains of S. koreensis elucidated the existence of a reservoir in the hospital plumbing. Clinical S. koreensis isolates from other facilities were genetically distinct from the NIH isolates. Hospital remediation strategies were guided by results of microbiologic culturing and fine-scale genomic analyses. CONCLUSIONS: This genomic and epidemiologic investigation suggests that S. koreensis is an opportunistic human pathogen that both persisted in the NIH Clinical Center infrastructure across time and space and caused health care-associated infections. (Funded by the NIH Intramural Research Programs.).

Establishing Clinical Pharmacy Services With Prescribing Privileges in a Federally Qualified Health Center Primary Care Clinic.

OBJECTIVES: To describe the process and cost of establishing clinical pharmacy services with prescribing privileges in a federally qualified health center (FQHC) primary care clinic. SETTING: The primary care clinic was located in a low-income area of Southern California and served patients with Medicaid and Medicare. The primary care clinic had preventive medicine and family medicine physicians, a family medicine residency program, behavioral health services, and a registered dietician. PRACTICE INNOVATION: New clinical pharmacy services were established at this FQHC primary care clinic. The medication assistance program was a stepping stone to establish rapport with the physicians. Credentialing and privileging was implemented for clinical pharmacists. An open protocol collaborative practice agreement was developed to allow clinical pharmacists to manage ambulatory patients. RESULTS: From August 2014 to June 2015, the clinical pharmacist interacted with 392 patients and spent 336 hours educating patients and providing disease state management. The pharmacist also provided consults to residents and providers. Diabetic patients made up 76% of all clinical pharmacy encounters. There were 86 face-to-face clinical pharmacy appointments with the pharmacist. The average time for clinical pharmacy appointments was 77 minutes. CONCLUSION: By describing ways to develop rapport with providers, how to credential and privilege pharmacists, and explain resources and costs of setting up a service, the hope is that more clinical pharmacists will be able to incorporate into independent or FQHC primary care clinics for improved management of ambulatory patients.

Improving Quality of Care in Federally Qualified Health Centers Through Ambulatory Care Accreditation.

HRSA supported health centers have a long history of participating in ambulatory care accreditation; however, there is a dearth of information on the relationship between accreditation and quality of care. We conducted a cross-sectional study of 1,202 health centers, using multivariate regression to estimate the association between accreditation and 14 clinical quality measures, controlling for patient and organizational characteristics. We also predicted national estimates of accreditation-related improvement in quality. Adjusted analyses show that accredited health centers achieved higher performance on adult weight screening and follow-up (coef = 0.037, p < .05), tobacco cessation intervention (coef = 0.042, p < .05), and use of lipid-lowering therapy (coef = 0.028, p < .05). Study results show that universal accreditation could result in additional 552,087 adult patients receiving weight screening and follow-up, 157,434 receiving tobacco cessation intervention and 25,289 receiving lipid-lowering therapy. This is the first national study to examine the impact of accreditation on health center quality of care. Findings suggest that HRSA support for accreditation has the potential to improve quality of care and as a result, reduce health disparities in underserved communities across the United States. Further research is necessary to identify specific elements of accreditation that have the greatest impact on quality of care.

Comparison of seropositivity of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and syphilis among Hospital Cornea Retrieval Programme-Donors versus voluntary cornea donors at a large eye bank in Eastern India.

PURPOSE: To compare the serology profile of donors from Hospital Cornea Retrieval Programme-donors (HCRP-D) and voluntary cornea donors (VC-D) from a large eye bank in Eastern India. METHODS: This is a retrospective analysis of donor details from January 2011 to December 2016. Donor demographics, cause of death, and serology reports were compiled. Postmortem blood was tested for human immunodeficiency virus 1 and 2 (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis using government-approved kits as per the National Programme for Control of Blindness Standards of Eye Banking. Donors for whom serology was not possible were excluded. RESULTS: A total of 4300 of 4353 donors were included of which 74.3% were hospital donors and 25.7% were voluntary donors. A total of 93 (2.2%) donors with 94 seropositive reports were noted: 79 (84.9%) from HCRP-D and 14 (15.1%) from VC-D which was statistically significantly higher (P = 0.02). Among seropositive reports, HIV, HBV, HCV, and syphilis accounted for 12 (12.8%), 38 (40.4%), 36 (38.3%), and eight (8.5%), respectively. There was no correlation between the cause of death and seropositivity. A statistically significant decreasing trend in seroprevalence among hospital donors was observed over the years (5.3% in 2011 to 1.4% in 2016; P = 0.004). Two (0.47%) of 421 hospital donors with prior negative serology were found to be seropositive. CONCLUSION: Seropositive rates are significantly higher among hospital donors in spite of medical prescreening compared to nonscreened voluntary donors. Serology should be repeated even when prior reports are available.

The process of defining the hospital care profile in federal hospitals in the city of Rio de Janeiro, Brazil. / O processo de conformação do perfil assistencial nos hospitais federais da cidade do Rio de Janeiro, Brasil.

This article analyzes the process of shaping the care profile of federal hospitals in the city of Rio de Janeiro. This is a qualitative, descriptive study that draws on semi-structured interviews with hospital administrators. Data analysis used the Collective Subject Discourse approach. Managers believe this process is the result of a set of emerging strategies, proposals and need for change, which result in adaptive reactions that hospitals develop with no coordination between them to resolve problems identified by professionals and managers. The process is analyzed much more from a political point of view than from a rational and systemic one. Some of the experience with the hospital mission, such as the focus on a strategic approach, already signals a more collegiate approach to defining the profile of care, where the hospital is one component of an integrated network of services, with a decision process that is less incremental and more integrating.