Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs.

Objectives: The intensive care unit (ICU) Liberation "ABCDEF" Bundle improves outcomes in critically ill adults. We aimed to identify common barriers to Pediatric ICU Liberation Bundle element implementation, to describe differences in barrier perception by ICU staff role, and to describe changes in reported barriers over time. Study Design: A 91-item survey was developed based on existing literature, iteratively revised, and tested by the PICU Liberation Committee at Seattle Children's Hospital, a tertiary free-standing academic children's hospital. Voluntary surveys were administered electronically to all ICU staff twice over 4-week periods in 2017 and 2020. Survey Respondents: 119 (2017) and 163 (2020) pediatric and cardiac ICU staff, including nurses (n = 142, 50%), respiratory therapists (RTs) (n = 46, 16%), attending and fellow physicians, hospitalists, and advanced practice providers (APPs) (n = 62, 22%), physical, occupational, and speech-language pathology therapists (n = 25, 9%), and pharmacists (n = 7, 2%). Measurements and Main Results: Respondents widely agreed that increased workload (78%-100% across roles), communication (53%-84%), and lack of RT-directed ventilator weaning (68%-88%) are barriers to implementation. Other barriers differed by role. In 2020, nurses reported liability (59%) and personal injury (68%) concerns, patient severity of illness (24%), and family discomfort with ICU liberation practices (41%) more frequently than physicians and APPs (16%, 6%, 8%, and 19%, respectively; P < .01 for all). Between 2017 and 2020, some barriers changed: RTs endorsed discomfort with early mobilization less frequently (50% vs 11%, P = .028) and nurses reported concern for patient harm less frequently (51% vs 24%, P = .004). Conclusions: Implementation efforts aimed at addressing known barriers, including educating staff on the safety of early mobility, considering respiratory therapist-directed ventilator weaning, and standardizing interdisciplinary discussion of Pediatric ICU Liberation Bundle elements, will be needed to overcome barriers and improve ICU Liberation Bundle implementation.

The Effect of an Empowerment Program on the Perceived Risk and Physical Health of Patients With Coronary Artery Disease.

This study was conducted to assess the effect of an empowerment program on the perceived risk and physical health of patients with coronary artery disease. This randomized clinical trial recruited 84 patients with coronary artery disease admitted to post-cardiac care unit (CCU) wards in Tehran Heart Center in 2017. The study subjects were selected and assessed according to inclusion criteria and assigned to intervention and control groups by block randomization. Both groups completed questionnaires for demographic details and disease history, perceived risk in cardiac patients, and physical health. The Magic Empowerment Program was performed for the intervention group as 3 workshops on 3 successive days. Intervention continued after patients' discharge from the hospital through phone calls once a week for 8 weeks. The perceived risk in cardiac patients and physical health questionnaires were completed for both groups. Postintervention results showed significant differences between the 2 groups in total score of perceived risk (P = .001) and its subscales. The Empowerment Program changed patients' attitudes toward risk-motivating behavior change and improving physical health.

Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project.

OBJECTIVES: To evaluate the effect of implementation of a comfort algorithm on infusion rates of opioids and benzodiazepines in postneonatal postoperative pediatric cardiac surgery patients. DESIGN: A quality improvement project, using statistical process control methodology. SETTING: Twenty-five-bed tertiary care pediatric cardiac ICU in an urban academic Children's hospital. PATIENTS: Postoperative pediatric cardiac surgery patients. INTERVENTIONS: Implementation of a guided comfort medication algorithm which consisted of key components; a low dose opioid continuous infusion, judicious use of frequent as needed opioids, initiation of dexmedetomidine infusion postoperatively, and minimal use of benzodiazepines. MEASUREMENTS AND MAIN RESULTS: Among the baseline group admitted over the 18 month period prior to comfort algorithm implementation, 58 of 116 intubated patients (50%) received a continuous opioid infusion, compared with 30 of 41 (73%) for the implementation group over the 9-month period following implementation. Following algorithm implementation, opioid infusion rates were decreased and benzodiazepine infusions were nearly eliminated. Dexmedetomidine use and infusion rates did not change. Although mean duration of sedative drug infusions did not change with implementation, the frequency of high outliers was diminished. Duration of mechanical ventilation, length of ICU stay (outcome measures), and the frequency of unplanned extubation (balancing measure) were not affected by implementation. CONCLUSIONS: Implementation of a pediatric comfort algorithm reduced opioid and benzodiazepine dosing, without compromising safety for postoperative pediatric cardiac surgical patients.

Determining the impact of a bowel management protocol on patients and clinicians' compliance in cardiac intensive care: A mixed-methods approach.

BACKGROUND: Bowel management protocols standardise care and, potentially, improve the incidence of diarrhoea and constipation in intensive care. However, little research exists reporting compliance with such protocols in intensive care throughout patients' stay. Furthermore, there is a limited exploration of the barriers and enablers to bowel management protocols following their implementation, an important aspect of improving compliance. AIM AND OBJECTIVE: To investigate the impact of a bowel management protocol on the incidence of constipation and diarrhoea, levels of compliance, and to explore the enablers and barriers associated with its use in intensive care. METHODS: A mixed-methods study was conducted in cardiac intensive care using two phases: (a) a retrospective case review of patients' hospital notes, before and after the protocol implementation, establishing the levels of diarrhoea and constipation and levels of compliance; (b) focus groups involving users of the protocol, 6 months following its implementation, exploring the barriers and enablers in practice. RESULTS AND FINDINGS: Fifty-one patients' notes were reviewed during phase one: 30 pre-implementation and 21 post-implementation. Following the protocol implementation, there was a tendency for a higher incidence of constipation and less severe cases of diarrhoea. Overall compliance with the protocol was low (2.3%). However, there was evidence of behavioural change following protocol implementation, including less variation in aperients given and a shorter, less varied time period between starting enteral feed and administering aperients. Several themes emerged from the focus groups: barriers and enablers to the protocol characteristics and dissemination; barriers to bowel assessment; nurse as a barrier; medical involvement and protocol outcomes. CONCLUSIONS: The bowel management protocol implementation generated some positive outcomes to bowel care practices. However, compliance was low and until there is improvement, through overcoming the barriers identified, the impact of such protocols in practice will remain largely unknown.

Identifying the Factors Affecting Comfort and the Comfort Levels of Patients Hospitalized in the Coronary Care Unit.

Comfort, a concept associated with the art of nursing, is important for reducing the negative impact of hospitalization in a coronary care unit (CCU). Providing nursing interventions that ensure patient comfort is important for patients to respond positively to treatment. To determine the factors affecting comfort and the comfort levels of patients hospitalized in the CCU. A descriptive study. The study was conducted between December 2015 and February 2016 in the CCU of a state hospital located in Trabzon, Turkey. The sample consisted of 119 patients who complied with the criteria of inclusion for the study. Data were collected using the "Patient Information Form" and a "General Comfort Questionnaire." The mean patient comfort score was 3.22 ± 0.33, and we found significant relationships between comfort scores and age (r = -0.19; P = .03) and communication by nurses and physicians (P < .05). Regression analysis revealed that sufficient communication by physicians, education level, age, and having a companion were related to the comfort level (P < .05). Communication by nurses and physicians and having a companion could change the comfort levels of patients hospitalized in the CCU.

Reducing Pressure Injuries in a Pediatric Cardiac Care Unit: A Quality Improvement Project.

The purpose of this quality improvement project was to develop an evidence-based protocol designed for pressure injury prevention for neonates and children in a pediatric cardiac care unit located in the Midwestern United States. The ultimate goal of the project was dissemination across all pediatric critical care and acute care inpatient arenas, but the focus of this initial iteration was neonates and children requiring cardiac surgery, extracorporeal support in the form of extracorporeal membranous oxygenation and ventricular assist devices in the cardiac care unit, or cardiac transplantation. A protocol based upon the National Pressure Ulcer Advisory Panel guidelines was developed and implemented in the pediatric cardiac care unit. Pediatric patients were monitored for pressure injury development for 6 months following protocol implementation. During the 40-month preintervention period, 60 hospital-acquired pressure injuries (HAPIs) were observed, 13 of which higher than stage 3. In the 6-month postintervention period, we observed zero HAPI greater than stage 2. We found that development and use of a standardized pressure injury prevention protocol reduced the incidence, prevalence, and severity of HAPIs among patients in our pediatric cardiac care unit.

The Cardiovascular Intensive Care Unit-An Evolving Model for Health Care Delivery.

Prior to the advent of the coronary care unit (CCU), patients having an acute myocardial infarction (AMI) were managed on the general medicine wards with reported mortality rates of greater than 30%. The first CCUs are believed to be responsible for reducing mortality attributed to AMI by as much as 40%. This drastic improvement can be attributed to both advances in medical technology and in the process of health care delivery. Evolving considerably since the 1960s, the CCU is now more appropriately labeled as a cardiac intensive care unit (CICU) and represents a comprehensive system designed for the care of patients with an array of advanced cardiovascular disease, an entity that reaches far beyond its early association with AMI. Grouping of patients by diagnosis to a common physical space, dedicated teams of health care providers, as well as the development and implementation of evidence-based treatment algorithms have resulted in the delivery of safer, more efficient care, and most importantly better patient outcomes. The CICU serves as a platform for an integrated, team-based patient care delivery system that addresses a broad spectrum of patient needs. Lessons learned from this model can be broadly applied to address the urgent need to improve outcomes and efficiency in a variety of health care settings.

Modern Management Practices and Hospital Admissions.

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

Developmental Care in North American Pediatric Cardiac Intensive Care Units: Survey of Current Practices.

BACKGROUND: Developmental care practices across pediatric cardiac intensive care units (CICUs) have not previously been described. PURPOSE: To characterize current developmental care practices in North American CICUs. METHODS: A 47-item online survey of developmental care practices was developed and sent to 35 dedicated pediatric CICUs. Staff members who were knowledgeable about developmental care practices in the CICU completed the survey. FINDINGS/RESULTS: Completed surveys were received from 28 CICUs (80% response rate). Eighty-nine percent reported targeted efforts to promote developmental care, but only 50% and 43% reported having a developmental care committee and holding developmental rounds, respectively. Many CICUs provide darkness for sleep (86%) and indirect lighting for alertness (71%), but fewer provide low levels of sound (43%), television restrictions (43%), or designated quiet times (21%). Attempts to cluster care (82%) and support self-soothing during difficult procedures (86%) were commonly reported, but parental involvement in these activities is not consistently encouraged. All CICUs engage in infant holding, but practices vary on the basis of medical status and only 46% have formal holding policies. IMPLICATIONS FOR PRACTICE: Implementation of developmental care in the CICU requires a well-planned process to ensure successful adoption of practice changes, beginning with a strong commitment from leadership and a focus on staff education, family support, value of parents as the primary caregivers, and policies to increase consistency of practice. IMPLICATIONS FOR RESEARCH: Future studies should examine the short- and long-term effects of developmental care practices on infants born with congenital heart disease and cared for in a pediatric CICU.

The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions.

The organization of networks in order to better coordinate and to faster offer reperfusion strategies for acute ST-elevation myocardial infarction (STEMI) is an important recommendation of recent versions of international guidelines. This article focusses on similarities and dissimilarities of world-wide networks, highlights essential network components, offers insights into still unmet needs and discusses potential measures to further improve quality of STEMI treatment.

ESC Working Group on Valvular Heart Disease position paper--heart valve clinics: organization, structure, and experiences.

BACKGROUND: With an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed. AIMS: The aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols. CONCLUSION: The growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.

New cardiac models of care reduce patient access to specialist nurses: a Victorian cross-sectional pilot study.

BACKGROUND: Several studies have shown that the acuity and complexity of patients admitted to coronary care units is rising. Advances in medical technology and management of these patients have resulted in shorter lengths of hospital stay. Together, these changing care patterns have led to an emergence of new models of care delivery that differ from traditional coronary care units (CCU). The effect of these new models on workforce and resources in this area is unknown. AIM: To describe the workforce and workplace resources of adult CCUs in Victoria, Australia. METHOD: This pilot study used an investigator-developed survey to audit all adult CCUs operating in Victoria in 2010. RESULTS: A total of 24 CCUs participated in the audit of which the majority were located in metropolitan public hospitals. In terms of model of care of CCUs: 25% (6) of CCUs were a combination of a CCU/cardiology ward, 17% (4) a combined CCU/ICU or combined CCU/ICU/HDU and 12.5% (3) of CCUs were a dedicated unit. Only 15% (4) of all units met the international standards for a nursing workforce with critical care qualifications. The CCU/day procedure/HDU models had 24% of critical care qualified staff followed by CCU/cardiology ward model with 35% compared to an average of 54-80% of qualified staff in the other models of care of CCU. CONCLUSIONS: This pilot study has highlighted the heterogeneity in models of CCU and a shortage of qualified critical care nurses, particularly in the CCU/cardiology ward model. This may have implications for the quality of care delivered in CCUs.

A model to create an efficient and equitable admission policy for patients arriving to the cardiothoracic ICU.

OBJECTIVE: To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons. DESIGN: Retrospective analysis of 6-month unit admission data from a cohort of cardiothoracic surgical patients, to create queuing and simulation-based models of ICU bed flow. Three different admission policies (current admission policy, shortest-processing-time policy, and a dynamic policy) were then analyzed using simulation models, representing 10 yr worth of potential admissions. Important output data consisted of the "average waiting time," a proxy for unit efficiency, and the "maximum waiting time," a surrogate for patient equity. SETTING: A cardiothoracic surgical ICU in a tertiary center in New York, NY. PATIENTS: Six hundred thirty consecutive cardiothoracic surgical patients admitted to the cardiothoracic surgical ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Although the shortest-processing-time admission policy performs best in terms of unit efficiency (0.4612 days), it did so at expense of patient equity prolonging surgical waiting time by as much as 21 days. The current policy gives the greatest equity but causes inefficiency in unit bed-flow (0.5033 days). The dynamic policy performs at a level (0.4997 days) 8.3% below that of the shortest-processing-time in average waiting time; however, it balances this with greater patient equity (maximum waiting time could be shortened by 4 days compared to the current policy). CONCLUSIONS: Queuing theory and computer simulation can be used to model case flow through a cardiothoracic operating room and ICU. A dynamic admission policy that looks at current waiting time and expected ICU length of stay allows for increased equity between patients with only minimum losses of efficiency. This dynamic admission policy would seem to be a superior in maximizing case-flow. These results may be generalized to other surgical ICUs.

Administrative hospitalization database validation of cardiac procedure codes.

BACKGROUND: Although cardiac procedures are commonly used to treat cardiovascular disease, they are costly. Administrative data sources could be used to track cardiac procedures, but sources of such data have not been validated against clinical registries. OBJECTIVES: To examine accuracy of cardiac procedure coding in administrative databases versus a prospective clinical registry. SAMPLE: We examined a total of 182,018 common cardiac procedures including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, valve surgery, and cardiac catheterization procedures during fiscal years 2005 and 2006 across 18 cardiac centers in Ontario, Canada. RESEARCH DESIGN: Accuracy of codes in the Canadian Institute for Health Information (CIHI) administrative databases were compared with the clinical registry of the Cardiac Care Network. RESULTS: Comparing 17,511 CIHI and 17,404 registry procedures for CABG surgery, the positive predictive value (PPV) of CIHI-coded CABG surgery was 97%. In 6229 CIHI-coded and 5885 registry-coded valve surgery procedures, the PPV of the administrative data source was 96%. Comparing 38,527 PCI procedures in CIHI to 38,601 in the registry, the PPV of CIHI was 94%. Among 119,751 CIHI-coded and 111,725 registry-coded cardiac catheterization procedures, the PPV of administrative data was 94%. When the procedure date window was expanded from the same day to ±1 days, the PPV was 96% (PCI) and exceeded 98% (CABG surgery), 97% (valve surgery), and 95% (cardiac catheterization). CONCLUSIONS: Using a clinical registry as the gold standard, the coding accuracy of common cardiac procedures in the CIHI administrative database was high.

Clinical quality improvement: eliminating unplanned extubation in the CCU.

PURPOSE: This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months. DESIGN/METHODOLOGY/APPROACH: Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds. FINDINGS: For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours. PRACTICAL IMPLICATIONS: Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU. ORIGINALITY/VALUE: There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.

Changes in health service delivery for cardiac patients: implications for workforce planning and patient outcomes.

BACKGROUND: Traditional dedicated coronary care units (CCU) are being decommissioned and cardiology precincts are evolving. These precincts often have cardiac and non-cardiac patients with a diverse array of acuity levels. Critical care trained cardiac nurses are frequently caring for lower acuity patients resulting in a deskilling of this experienced workforce. AIM: The aim of this paper was to discuss the implications of restructuring CCUs on nursing workforce and patient outcomes. METHOD: An integrated literature review was conducted. The following databases were searched for articles published between January 2000 and December 2011: Ovid Medline, CINHAL, EMBASE and Cochrane. Additional studies obtained from the articles searched and policy documents from key professional organisations and government departments were reviewed. RESULTS: This review has highlighted the association between workforce, qualifications and quality of care. Studies have shown the relationship between an increase in critical care qualified nursing staff and an improvement in patient outcomes. Inadequate staffing levels were also shown to be associated with an increase in adverse events. Cardiology precincts have the potential to adversely impact on critical care trained cardiac nursing workforce and patient outcomes. CONCLUSION: The implications that these new models have on the critical care cardiac nurse workforce are crucial to health care reform, quality of in-hospital care, sentinel events and patient outcomes.

Personnel and unit factors impacting outcome after cardiac arrest in a dedicated pediatric cardiac intensive care unit.

OBJECTIVE: To assess the impact of personnel and unit factors on outcome from cardiac arrest in a dedicated pediatric cardiac intensive care unit. DESIGN: Retrospective medical record review. SETTING: Dedicated cardiac intensive care unit at a quaternary academic children's hospital. PATIENTS: Children and young adults who had cardiac arrest while cared for in the pediatric cardiac intensive care unit from January 1, 2006, to December 31, 2008. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred two index cardiac arrests over a 3-yr period in our pediatric cardiac intensive care unit were reviewed. We defined successful resuscitation as either return of spontaneous circulation or successful cannulation to extracorporeal membrane oxygenation. Differences in resuscitation rates were assessed across categorical systems variables using logistic regression. The rate of successful resuscitation was 84% (return of spontaneous circulation 74%, extracorporeal membrane oxygenation 10%). Survival to hospital discharge was 48% for patients who had a cardiac arrest. 11% of arrests during the week and 31% during weekends (odds ratio 3.8; 95% confidence interval 1.2-11.5) were not successfully resuscitated. Unsuccessful resuscitation was significantly more likely when the primary nurse had <1 yr of experience in the pediatric cardiac intensive care unit (50% <1 yr vs. 13% >1 yr; odds ratio 6.8; confidence interval 1.5-31.0). Cardiac arrest on a weekend day and <1-yr pediatric cardiac intensive care unit nursing experience were also associated with unsuccessful resuscitation in a multivariable model. Resuscitation outcomes were similar when senior intensive care unit attending physicians were on-call at the time of arrest compared with other intensive care unit staff (17% unsuccessful vs. 15%; odds ratio 1.2; confidence interval 0.4-3.7). Arrests where the attending physician was present at the onset resulted in unsuccessful resuscitation 18% of the time vs. 14% for events where the attending was not present (odds ratio 1.3; confidence interval 0.5-3.9). CONCLUSIONS: Our data suggest that personnel and unit factors may impact outcome after cardiac arrest in a pediatric cardiac intensive care unit. Weekend arrests and less experience of the primary nurse were risk factors for unsuccessful resuscitation. Neither presence at arrest onset nor experience of the attending cardiac intensivist was associated with outcome.

Superior outcome with direct catheter laboratory access vs ED-activated primary percutaneous coronary intervention.

AIMS: Admitting patients directly to a heart attack center (HAC) catheter laboratory for primary percutaneous coronary intervention (PPCI) bypassing the emergency department (ED) might be beneficial in delivering treatment of ST-elevation myocardial infarction with superior outcome. METHODS: In this analysis, the clinical outcome of service redesign of the PPCI pathway from ED triggered to a direct catheter laboratory HAC access was assessed in 361 consecutive patients with ST-elevation myocardial infarction treated with a PPCI. RESULTS: A total of 200 patients were admitted via the ED, and 161 were admitted directly to the HAC. Door-to-balloon times and call-to-balloon times were significantly better in the HAC group (median [interquartile range] door-to-balloon times and call-to-balloon times were 39 [26, 53] and 106 [91, 132] minutes, respectively) in comparison with the ED group (82 [49,120; P < .0001] and 130 [103, 164] minutes, respectively [P = .0005]). A nonsignificant trend to a lower 30-day (5% in the HAC group and 6% in the ED group) and 17-month (8% in HAC group and 11% in ED group) mortality was seen in the HAC group (P = .63). Composite end point analysis of left ventricular ejection fraction less than 50%, thrombolysis in myocardial infarction grades 0 and 1, and myocardial blush scores 0 and 1 showed that a significantly higher number of patients in the ED group experienced at least 1 of the composite events in comparison with the patients in the HAC group (P = .01). CONCLUSION: A direct-access catheter laboratory (HAC) model of PPCI bypassing the ED should be the favored approach to service delivery with superior outcome.