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Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
Patient- and Family Centered Care: "Resident Performance from the Patient's View"
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Patient- and Family Centered Care: "Resident Performance from the Patient's View"

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  • I’ll start with a quote from our website that exhorts our specialization in patient centered care…..I do this to set the stage for what I am going to talk about and let you make your own decisions about whether this is true or not?I think we have challenges and room to grow in this area.
  • Transcript

    • 1. Patient and Family Centered Care (PFCC): Lessons from Graduate Medical Education
      Medicine Grand Rounds March 15th, 2011
      Richard M. Wardrop III, M.D., Ph.D.
      WakeMed Faculty Physicians
    • 2. Disclosure
      I had grant support to perform research from the Picker Institute and ACGME
      I currently serve as an external reviewer to the Picker Institute and their challenge grant program
    • 3. Full Disclosure - My Research Focus
      Then
      Now
    • 4. Objectives
      Introduction
      Review what PFCC is
      Review history of PFCC
      Give resources for PFCC practice
      Show examples of successful implementation of PFCC in GME and beyond
      Research
      Share some data from my experience at Carilion
      Mixed methods project
      Speculate on what we can do here in PFCC and in GME
    • 5. Background Setting
      The PFCC movement is enormous
      There is no fixed history
      Multiple players on multiple levels
      The work of others is very humbling
      Just good medical practice?
      We have to start somewhere….
    • 6. How can I get you to practice PFCC?
      Patients like it?
      Patients feel empowered?
      It saves money?
      It leads to safer care?
      It does not cost anything extra?
      Anyone can do it?
    • 7. We are (I was 2008 – 2010)…..Carilion Clinic
      500+ physicians in a multi-specialty group practice and eight not-for-profit hospitals.
      Specializing in patient-centered care, medical education, and clinical research.
    • 8. What is PFCC?
      “Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care patients, families, and providers.”
      “Patient- and family-centered care applies to patients of all ages, and it may be practiced in any health care setting “
      www.familycenteredcare.org
    • 9. Core Values of PFCC
      Dignity and Respect
      Information Sharing
      Participation
      Collaboration
    • 10. Core Values of PFCC – Picker Institute
      Respect for patient values, preferences, and expressed needs
      Coordination and integration of care
      Information, communication, and education
      Emotional support and alleviation of fear and anxiety
      Inclusion of family in care
      Transition and continuity
      Physical Comfort
      Access to care
      www.pickerinstitute.org
    • 11. Core Values of PFCC
      Belief oriented….Planetree Foundation
      that we are human beings, caring for other human beings
      we are all caregivers
      care giving is best achieved through kindness and compassion
      safe, accessible, high quality care is fundamental to patient centered care
      is a holistic approach to meeting people's needs of body, mind and spirit
      families, friends and loved ones are vital to the healing process
    • 12. Core Values of PFCC
      Belief oriented….cont
      access to understandable health information can empower individuals to participate in their health.
      the opportunity for individuals to make personal choices related to their care is essential
      physical environments can enhance healing, health and wellbeing
      illness can be a transformational experience for patients, families and caregivers
      www.planetree.org
    • 13. Pause
      Pause…. Are you saying….
      “I agree with that – why do we need to hear this?”
      “I already do all these things…I’m good”
      Or are you saying “I want to do more but the system won’t let me….”
      “I’m to busy to worry about this…..”
      Out of respect for my audience… welcome your thoughts
    • 14. Brief History of PFCC – Divergent Events / Efforts Converging on a point….
      Started with the Planetree Foundation in 1978
      Had many roots in pediatrics and HIV/AIDS population
      A system in need of major change – Institute of Medicine Reports and C.E. Coop
    • 15. Brief History of PFCC
      The Institute for Family Centered Care
      Picker Institute for Patient Centered Care
      Center for Patient and Family Centered Care - MCG
      National Priorities Partnership
      AHRQ, CDC, CMS, IOM, Joint Commission and 20+ others
      Defined Priorities in Patient Care – many of which adhere to PFCC principles
      www.qualityforum.org/about/npp
    • 16. Brief History of PFCC
      Other Organizations involved with guidelines or statements
      SCCM
      ABIM
      American Hospital Association
      American Academy of Orthopedic Surgeons
      Countless medical centers recognized
    • 17. Resources
      Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices – free 178 page document
      Supported by RWJ
      Other titles available from evidence based architecture to bibliographies for resources and references
      http://www.familycenteredcare.org/resources/other/index.html
    • 18. Resources
      Picker Institute
      Picker Surveys
      Challenge grants
      Profiles of successful Centers
      Downloadable seminars and workshops
      Other grants and resources
      http://www.pickerinstitute.org/Research/pickerchallenge.html
    • 19. Reading and Resources for GME
      GME Assessment and Tips
      Books
      Downloads….from ABIM
      http://www.abimfoundation.org/
    • 20. Making it real…..
      Real examples from a large teaching institution……
    • 21. Beacon of PFCC
      Medical College of Georgia
      http://cpfcc.org
      Started movement in 1993 by including patients in design of Children's Hospital
      In 2002 set behavioral standards for all staff
    • 22. MCG – UME and GME
      Since 1993
      Institutional commitment to change clinical environments to PFCC
      Developed family faculty for patients and families to serve as expert advisors and teachers
      Foster resident involvement with family and patient advisors
      Create opportunities that allow residents to apply this to their practice
      Developed standards for how teaching rounds will take place
    • 23. MCG – UME and GME
      Teaching examples at MCG
      MS Clinic
      Behavioral Health
      Cystic Fibrosis
      Family Medicine Clinic
      Cancer Center
      Peri-natal clinic
      Research
      ePHR HTN project
      Involve patients and families in faculty and resident recruitment
      Integrate patients and families into research efforts
    • 24. Relating ACGME Competencies to PFCC at MCG in GME
    • 25. PFCC Success….in a clinical unit
      Neurosciences Center of Excellence - at MCG: PFCC experience
      Patient satisfaction 10%-95th%tile
      Length of stay on Neurosurgery decreased 50%
      62% decrease in medication errors
      Staff vacancy from ~8%  0% (wait list)
    • 26. MCG Institutional Improvement?
      Increased / Improved
      Patient satisfaction
      Clinical quality
      Payer mix
      Market share
      Profitability
      Decreased
      Malpractice claims
      Show me the Money!
      Featured in PBS Documentary – Remaking of American Medicine
    • 27. Summary
      PFCC has a 30 year history at least
      At its deepest levels, we probably all agree with it
      Differences are in the execution
      Research exists
      Success stories exist
      Real improvements in a medical center can happen
      It can not only co-exist with GME but also drive GME
    • 28. Resident performance from the patient’s view: A novel prospective assessment of performance and performance improvement in delivering patient-centered care
    • 29. A common motivating theme is some experience…..
      Dr. Harvey Picker – Picker Institute
      Angelica Thieriot – Planetree
      Me – what got me interested?
    • 30. Grand Parents and Parents
    • 31. The questions I started having as I started at Carilion
      Should doctors finish training without getting feedback from patients?
      If we give them feedback will they be better in cultivating good communication and productive relationships with patients and families?
    • 32. Medical Educators – Patient Care, Supervision, Teaching, and Feedback
    • 33. The Problem
      As a young attending I felt a few pieces of information were missing as I went to fill out the ACGME competency based evaluations….
    • 34. The Art of Feedback
      Make observations and collect facts
      Time and data dependant
      Need a framework to standardize feedback
      Provide a mirror image
    • 35. The Problem
      It occurred to me during my 7th or 8th two week block…
      when a patient fired one of the residents I was supervising and
      then a nurse complained about a different resident
      then a patient gave the same resident praise….
      I was not really sure what was going on between the residents and patients when I was not around to observe them.
    • 36. What to do?
      Spying?
      Using a wire tap?
      Video taping?
      Interrogating the patients?
      Sneaking around?
    • 37. What to do?
      Patient care is complex and emotional
      Supervising residents is complex
      There are only 24 hours in a day
      But I need to know!
    • 38. What to do?
      Sentinel events (firing by patients, complaints, or praise) cannot dominate the entire recorded experience all the time….
      How to empower and enlists the patients in the feedback process consistently?
    • 39. The Resources
      What did we have at our disposal to solve this problem...?
    • 40. What we had experimented with….
      How useful? Learner Centered? Patient Centered?
    • 41. Evolved into this….
      Learner Centered? Patient Centered?
    • 42. Opportunity knocks…
      We had problem / hypothesis
      Call for grants from OSP
      Struck me at the right time
      I had time
      We had core team
      We had resources
      There was money up for grabs
    • 43. Eureka! Make a new mousetrap…
      Distribute it to everyone
      Share the feedback with the residents
      Ask the patients anonymously about the residents using a survey
      Make it competency based
      Make it portable
      Make it easy
    • 44. Make a new mousetrap…
      Most of all make it patient centered
    • 45. Hypothesis and Aims
      Hypothesis - the regular use of the a patient-centered, core competency-based survey tool combined with specific learner centered feedback would improve the performance of residents in delivering patient-centered care when compared to the conventional practice of attending-only assessment and feedback.
    • 46. Hypothesis and Aims
      AIM 1: To adapt the evaluation tool into a concise, valid and reliable instrument that enables patients assess resident performance on 4/6 ACGME competencies.
      AIM 2: To compare residents who receive feedback and coaching using the tool developed under AIM 1 to traditional attending-only assessment and feedback.
    • 47. Picker Challenge Grant Program
      Started in 2005 for projects in 2006
      4 per year at $25,000
      Requires matching funds (in kind)
      2008 cycle had 119 applications
      Grants focused on research in PFCC in GME
      Picker Principles
      $50,000 total / project
      Transitioning Adolescent Patients (TAP) from Pediatric to Adult CarePrincipal investigator: Emily von Scheven, MD, MAS, Pediatric Rheumatology, University of California San Francisco
      Improving Patient Rounds (IPR)Principal investigator: Walter J. Moore, MD, Center for Patient- and Family-Centered Care, Medical College of Georgia
      Patient-Centered Training of Residents on a Medical Ward Principal investigator: Robert C. Smith, MD, MS, Internal Medicine,EW Sparrow Hospital/Michigan State University College of Human Medicine
      Resident Performance from the Patient’s ViewPrincipal investigator: R.M. Wardrop, MD, PhD, FAAP, Director of Resident Research, Internal Medicine, Carillion Clinic, Roanoke, Va.
    • 48. Our team upon receiving award
    • 49. The tool
    • 50. The tool – used by patients, residents and attending
    • 51. The Picker Principles - Assessed
      Respect for patient values, preferences, and expressed needs
      Coordination and integration of care
      Information, communication, and education
      Emotional support and alleviation of fear and anxiety
      Transition and continuity
    • 52. Hypothesis and Aims
      AIM 1: To adapt the evaluation tool into a concise, valid and reliable instrument that enables patients assess resident performance on 4/6 ACGME competencies.
      AIM 2: To compare residents who receive feedback and coaching using the tool developed under AIM 1 to traditional attending-only assessment and feedback.
    • 53. End points
      Quantitative
      Reliable?
      Valid and on how many scales?
      Measure performance
      Effect on performance when combined with feedback?
      Qualitative
      Patients appreciate?
      Residents appreciate?
      Comments have any meaningful content?
    • 54. Other measures
      Residents evaluate themselves in these patient centered domains
      Attending physicians evaluate residents in patient centered domains
      Conduct patient-centered interviews regarding the process
    • 55. Study Design
    • 56. Study Design
      Study Attending Intervention – provide usual coaching + coaching derived form PERPS)
      Attending Intervention – provide usual coaching
      July 2008-June 2009
      Month 1
      Month 2
      Month 3
      Month 4
      Feedback 1-1
      AERPS, RERPS
      Feedback 1-2
      PERPS, AERPS,
      RERPS
      Group 1
      (Usual evaluation)
      End evaluation, correlations
      Month 1
      Month 2
      Month 3
      Month 4
      Group 2
      (Patient Centered evaluation + usual evaluation)
      Feedback 2-1
      PERPS, AERPS,
      RERPS
      Feedback 2-2
      PERPS, AERPS,
      RERPS
      Study Attending Intervention – provide usual coaching + coaching derived form PERPS)
      Study Attending Intervention – provide usual coaching + coaching derived form PERPS)
    • 57. Patient Questionnaire Distribution
    • 58. Patient Questionnaire Collection
    • 59. We did the unthinkable…
      Selected patient interviews by study faculty
      To focus survey
      Have patients tell us what the questions mean to them in their own words.
    • 60. Patient Interview Data
    • 61. Patient Interview Data
    • 62. Patient Interview Data
    • 63. Patient Interview Data
    • 64. Patient Interview Data
    • 65. Scale Validity and Reliability
      Reliability (consistency)
      Consistency in the ratings on any measure is important
      Differences in rating not due to chance
      Measure Chronbach’s Alpha across all raters and ACGME domains
      All were >0.75 indicating the scale and the raters were using it consistently
      Validity (accuracy)
      Assessing validity determines whether or not the survey is measuring what it was intended to measure
      The instrument had built-in content validity
      Structural validity testing only found 1 valid scale with no subscales (patients and attending rated with little variability between domains (good in one good in all)
    • 66. Sample Comments from Patients (over 300 written)
      The good
      “I know this looks like we just circled all 5's but Dr B. truly met all of them. Our family was REALLY impressed with Dr B. of all the doctors we have seen. He stands at the top.” +/PC/ICS/P
      “Dr T shows great leadership, he is a listener and very helpful to me about getting to the problem and ruling out disease and ordering tests and explaining special tests. He LISTENS. That smile also will take him a long way. I'm glad he was on my team of recovery. My heart goes (out to him).” +/P/PC/ICS
      “Very compassionate, caring and professional. Takes time to listen to pts. (the resident) explained everything to myself and family in layman's terms to understand. Excellent Dr. Wish him success in the world. Thanks for excellent care.” +/PC/P/ICS
      Other
      “He (the resident) seems caring my only problem is its hard to understand his when he's talking. Otheriwise he seems OK. I've only seen him once since my husband's been here. Everyone else has been very good to him.” +/-P/ICS
      “No contact. I have been in the hosp for over 35 hrs in this 3 day stay and never spoke with this Dr. (written by wife)” - P/ICS
    • 67. Content of Comments from Patients (n=100)
    • 68. Next Phase – Learner Feedback
      Standardized
      Scripted
      Based on scores from patients, self, and attending
      Open ended and closed ended questions
    • 69. Resident Reponses to Feedback
    • 70. Resident Reponses to Feedback
    • 71. Sample Resident Comments
      Name two distinct things you learned from this process about yourself or about how patients view you.
      “I thought the patients would be more concerned with my medical decision making”
      “glad to know I helped my patients so much – it makes it easier to work so hard knowing this”
      “Patients value giving input into care”
      “Patient’s know what is going on with their care”
      “It was more positive than I expected”
      “the patients view me more favorably than I thought”
      “I am my own worst critic”
      “Patients think I am a great doctor”
      “I need to interrupt patients less”
      What one thing will you commit to change because of this process?
      “more discussion of the plan with patients or family”
      “I will stop interrupting patients so much”
      “Maybe going back to round on my patients in the afternoon (to update them)
      “trying to better incorporate patient preferences into management”
      Comments and suggestions?
      “Get as many back from patients as possible to assure accuracy”
      “Worried attending physicians may not be best to hand out the surveys may skew the results towards good evals to not get anyone in trouble”
      “Pleasant patients may get more attention”
      “Patients with multiple co-morbidities may not get a form as frequently and this could create bias”
    • 72. Resident Performance – prior to feedback
      No significant differences between groups prior to feedback
    • 73. Resident Performance – prior to feedback
      No significant differences between groups prior to feedback
    • 74. Resident Performance improved when associated with having received feedback – communication, patient care, systems based practice
      *
      *
      *
      *
      *
    • 75. Challenges for prime time use
      Curriculum
      Making sense of the data
      Validity and reliability testing in your populations
      Survey collection and distribution
      Finding meaning in the non-numerical data
    • 76. Conclusions
      Patients provided regular feedback using the instrument and scales
      Patient appreciated providing feedback
      The survey was reliable and valid. Scale validity for one scale
      Providing feedback during the year improved performance of residents in the patients’ and the attending physicians’ “eyes” in several areas
    • 77. Conclusions
      Patients regularly provided qualitatively rich and competency-based feedback
      Residents appreciate the feedback from the patients
      They feel it helps direct them for self- improvement in these areas
    • 78. Implications for WakeMed
      Use these resources / ideas at your own level
      Hospitalist face-card
      Do what you do only potentially change focus
      PFCC rounds on Pediatrics
      Stroke Rounds with MD
      Know who else feels this is important
      Ideas?
    • 79. Many thanks to….
      The Picker Institute
      ACGME leadership and staff
      Carilion Clinic
      Our team
      Our faculty
      Our residents
      Our patients
    • 80. Core Study Team
      Richard M. Wardrop III, MD, PHD, FAAP, FACP
      Chad J. DeMott, MD, FACP
      Jon M. Sweet , MD, FACP – Program Director
      David Baker, PhD
      Robert Herbertson, MS
      SowjanyaKolluri, MD
      RoshanBowansingh, MD
      Study Coordinators
      Dawn Bowles, RN
      Jacqueline Baker, RN
      Grant Management:
      W. Eryn Perry
    • 81. Thanks and Questions?
    • 82. Selected Bibliography
      Putting Patients First: Best Practices in Patient Centered Care, 2nd Ed. Susan Frampton and Patrick Charmel eds. Josey-Bass Publishers. San Francisco, 2008.
      Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices Institute for Family-Centered Care – 2008. Available online at www.familycenteredcare.org
      National Partnership Priorities Executive Report. National Priorities Partnership – at the National Quality Forum. November 2008. www.qualityforum.org
      Synthesis of Definitions of Patient-, Family-, and Relationship-Centered Care. Amy Cunningham. ABIM Foundation. www.abimfoundation.org
      Patient- and Family-Centered Care and Graduate Medical Education: A Primer. Beverely H. Johnson. Presented at 2009 ACGME Educational Conference, Grapevine, TX. www.acgme.org
      Patient- and Family-Centered Care and Resident Learning. Patricia Sodomka. Presented at 2009 ACGME Educational Conference, Grapevine, TX. www.acgme.org
    • 83. Selected WebBibliography
      Extensive references for specific specialties in PFCC available at the Institute for Family Centered Care www.familycenteredcare.org
      Planetree Foundation. All in one site with complete model and programs. www.planetree.org
      Additional resources results, links, survey tools, description of challenge grant awards and results available at www.pickerinstitute.org
      Center for Patient and Family Centered Care at UCG. Links, research in PFCC and GME research www.cpfcc.org

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