Tmp Cms Quality Lunch & Learn Final

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Tmp Cms Quality Lunch & Learn Final

  1. 1. SWO-HFMA : Lunch and Learn<br /> <br />Quality of Care<br />Cost Leadership, Methodology and Technology<br />October 30, 2009<br />Presenters:  Sunil Rao, MD, MBA, Chief Medical Officer, TMP<br /> Jeff Burke, MBA, Managing Partner, TMP<br /> <br />1<br />
  2. 2. www.T-M-Partners.net<br />2<br />
  3. 3. You will Learn<br />The importance of Quality to national healthcare reform<br />The financial impact Quality can have on every part of your hospital<br />The connection between “Meaningful Use”, the ARRA and EHR use; and the reporting of CMS Quality Core Measures<br />How to move from &quot;just reporting&quot; quality measures to a Quality Management Program for Improved Patient Outcomes based on methods and technology<br />The importance of real time data and process improvement methodologies to the critical issue of improving quality of care processes in healthcare<br />The critical part that (IT) information technology plays in the sustaining platform for continuous improvement<br />www.T-M-Partners.net<br />3<br />
  4. 4. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Finance and Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />4<br />
  5. 5. Thoughts for Today<br />Consider these issues:<br />Is Quality Improvement a “Burning Platform”?<br />In the long run, everything is focused on improving Quality<br />CMS says, Quality will improve their financial health<br />CMS may not care about your bottom line<br />CMS will pay the winners and penalize the others<br />ARRA will pay to accelerate IT adoption, but only based on Quality<br />Methods and Technologies can help<br />You need a Quality Improvement Roadmap and CEO Backing<br />www.T-M-Partners.net<br />5<br />
  6. 6. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Finance and Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />6<br />
  7. 7. Healthcare IndustryKey Quality Drivers<br />Patient-Centered Quality Care<br />Quality is a Board Level issue<br />Compliance is Required<br />CMS Pays for Performance<br />www.T-M-Partners.net<br />If Quality Outcomes had been improved by 2% in 2004, the national savings would have been:<br /><ul><li>5,700 avoidable death
  8. 8. 1 million hospital days
  9. 9. $1.4 billion</li></ul>Patient<br />Care<br />Better patient care costs hospitals less and improves patient outcomes<br />
  10. 10. 8<br />Eliminate Underuse<br />B<br />The Goal<br />A<br />The Industry Today<br />
  11. 11. Health Care Today | Misuse<br />Definition of Misuse<br />“Misuse” of care is another way of describing medical errors, which can be defined as either the failure to properly carry out appropriate treatment plans or the use of inappropriate plans. <br />Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academies Press, 1999.<br />
  12. 12. Health Care Today | Misuse<br />Deaths Due to Preventable Errors<br />Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academies Press, 1999.<br />
  13. 13. Health Care Today | Misuse<br />Deaths Due to Health Care-Associated Infections<br />Klevens RM, Edwards JR, Richards CL, Jr., et al. &quot;Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002.&quot; Public Health Reports, 122: 160-166, 2002.<br />
  14. 14. Health Care Today | Overuse<br />Definition of Overuse<br />When treatments are given without medical justification, such as antibiotics for simple infections, or when an equally effective option could have been followed that would have cost less or caused fewer side effects.<br />
  15. 15. Health Care Today | Overuse<br />Unnecessary—and Possibly Harmful—Services <br />Fisher ES, Goodman DC, Chandra A. Disparities in Health and Health Care among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Princeton, NJ: Robert Wood Johnson Foundation, 2008.<br />
  16. 16. Health Care Today | Underuse<br />Definition of Underuse<br />When patients do not receive medically necessary care, or when proven health care practices are not followed, e.g., when people who have heart attacks are not given beta-blocking drugs.<br />
  17. 17. Health Care Today | Underuse<br />Recommended Care<br />McGlynn EA, Asch SM, Adams J, et al. &quot;The Quality of Health Care Delivered to Adults in the United States.&quot; The New England Journal of Medicine, 348: 2635-2645 (26): 1, 2003.<br />
  18. 18. Health Care Today | Underuse<br />Deaths Due to Improper Care<br />Essential Guide to Health Care Quality. Washington: National Committee for Quality Assurance, 2007. (No authors given.)<br />
  19. 19. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Finance and Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />17<br />
  20. 20. News about Quality Every Day<br />CMS chief says Medicare should consider cost to determine coverage<br />CMS Director Dr. Barry Straube is expected to play a critical role in ensuring that health care spending is closely linked with the quality of care as White House officials and lawmakers scramble to pass a health care reform bill. Straube says cost should be considered in deciding which treatments should be covered by Medicare in order to address rising health care costs.<br />www.T-M-Partners.net<br />18<br />The Wall Street Journal (10/27/09) <br />
  21. 21. www.T-M-Partners.net<br /> “Payment reform will strengthen, if not codify, the relationship between payment and quality, with a significant amount of revenue at risk if quality goals are not achieved.”<br />Catherine Jacobson, FHFMA, CPA, Chair HFMA<br /> The HFMA believes that achieving the nation’s health goals requires effective reform of the payment system<br />Breaking Barriers<br />19<br />
  22. 22. Why is Quality so Important?<br />In the long run, everything is focused on improving Quality<br />CMS says, Quality will improve their financial health<br />Meaningful Use = CMS Quality Core Measures (Plus other items)<br />CMS<br />Pay for Reporting<br />Pay for Performance<br />Value Based Purchasing<br />ARRA<br />Certified EHR<br />Meaningful Use<br />www.T-M-Partners.net<br />20<br />CMS has been pursuing this since before 2005<br />Quality is worth it.<br />What is your Plan?<br />ARRA raises the ante and pays for faster action<br />
  23. 23. What Does VBP Mean to CMS?<br /><ul><li>Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care
  24. 24. Tools and initiatives for promoting better quality, while avoiding unnecessary costs
  25. 25. Tools: measurement, payment incentives, public reporting, conditions of participation, coverage policy, QIO program
  26. 26. Initiatives: pay for reporting, pay for performance, gainsharing, competitive bidding, bundled payment, coverage decisions, direct provider support</li></li></ul><li>Premier Hospital Quality Incentive Demonstration<br />
  27. 27. Health Care Today | Variations in Care<br />Overall Improvement is Slowing<br />National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality, 2008. (No authors given.)<br />
  28. 28. Additional Measure Topics for <br />FY 2010 and Beyond<br />
  29. 29. HACs Selected During IPPS FY 2008 Rulemaking<br />Foreign object retained after surgery<br />Air embolism<br />Blood incompatibility<br />Catheter-associated urinary tract infection<br />Vascular catheter-associated infection<br />Surgical site infection – mediastinitis after CABG<br />Pressure ulcers<br />Falls – specific trauma codes<br />
  30. 30. HAC, POA<br />“Since 2008, hospitals that cannot document certain conditions as POA have faced Medicare payment reductions. Medicare has also stopped paying for … Never Events. Next on the radar screen; Preventable Readmissions.<br />“Financial leaders should engage with clinicians to work toward avoiding preventable complecations – something both groups want. And we need to develop costing capabilities so we know what these events are costing us.<br />“It isn’t about the lost revenue anymore; it’s about preventing the complications and the associated costs in the first place.”<br />Catherine Jacobson, FHFMA, CPA, Chair HFMA<br />Letter from the Chair, HFM Magazine, October 2009<br />www.T-M-Partners.net<br />26<br />
  31. 31. ARRA – Hospital HIT<br />Medicare Funding Is Provided to Encourage the Adoption of HIT<br />ARRA Provisions<br />Implications for Hospitals<br /><ul><li>Hospitals Using Certified EHR During A Reporting Year Are Eligible.
  32. 32. Payment for Qualified Facilities Is Based on the “Medicare Share.”
  33. 33. Payments Are Phased Over Four Years Beginning in 2010.
  34. 34. Non-Adopting Hospitals Face Reduction to Three-Quarters of Their Medicare Market Basket Update, Starting in 2015
  35. 35. Early adopters will receive payments from Medicare during the implementation corridor, 2010 to 2015.
  36. 36. Laggards will see reductions in Medicare payments beginning 2015.
  37. 37. Monitor the Office of the National Coordinator for HIT to stay abreast of standards, specifications and certification criteria.
  38. 38. Instead of bolting EHR on top of existing processes, facilities should re-engineer patient care and billing workflows to increase efficiency and quality.
  39. 39. Base payment is $2M plus $200 per discharge for additional discharges from 1,150 to 23,000th
  40. 40. Reduced using a ratio based on Medicare utilization adjusted for charity care.</li></li></ul><li>ARRA – Hospital HIT<br />“Meaningful” users of HIT will receive additional payments from Medicare…<br />…while non-adopters will have their Medicare market basket update reduced <br />Percentage of HIT Medicare Share Payments Received Based on When Eligible<br />Percentage of Market Basket Update Received by Non-Adopters<br />2010 - 2013<br />2014<br />2015<br />2016<br />2015<br />2016<br />2017<br />Eligible in:<br />
  41. 41. Meaningful Use<br />“CMS is expected to publish a formal definition of meaningful use, for the purposes of receiving the Medicare and Medicaid incentive payments, by December 31, 2009.”<br />“Meaningful use of EHRs, we anticipate, will also enable providers to reduce the amount of time spent on duplicative paperwork and gain more time to spend with their patients throughout the day.<br />“Meaningful use, in the long-term, is when EHRs are used by health care providers to improve patient care, safety, and quality.<br />A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology<br />www.T-M-Partners.net<br />29<br />
  42. 42. Meaningful Use is Being Defined and Will Follow an “Ascension Path” Over Time*<br />2009<br />2011<br />2013<br />2015<br />HIT-Enabled Health Reform<br />Meaningful Use Criteria<br />HITECH Policies<br />2011 Meaningful Use Criteria (Capture/share data)<br />2013 Meaningful Use Criteria<br />(Advanced care processes with decision support)<br />2015 Meaningful Use Criteria (Improved Outcomes)<br />*Report of sub-committee of Health IT Policy Committee<br />
  43. 43. Policy Committee Recommendations for the Definition of Meaningful Use<br />
  44. 44. Cost of Poor QualityGeneric Model<br />Direct poor-quality cost<br />A. Controllable poor-quality cost     (1) Prevention cost --- Work to avoid an error      (2) Appraisal cost --- Work to assess error     (3) No-value-added cost --- Rework, Fix it<br />B. Resultant poor-quality cost    (1) Internal error cost --- LOS, Denials, HAC/POA    (2) External error cost --- Malpractice, UnPaid Care<br />Indirect poor-quality cost<br />A. Patient-incurred cost --- Time, Emotion, MoneyB. Patient-dissatisfaction cost --- ReputationC. Lost-opportunity cost --- Time and Capacity LostD. Loss-of-reputation cost --- Repeat, Referral, Payer<br />www.T-M-Partners.net<br />32<br />
  45. 45. Cost of Poor QualitySpecific Direct Costs (Unpaid)<br />www.T-M-Partners.net<br />33<br />
  46. 46. Poor Quality Impacts<br />www.T-M-Partners.net<br />34<br />
  47. 47. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Finance and Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />35<br />
  48. 48. SummaryTop 10 Things to do<br />Establish Executive Priority<br />Assess your current situation<br />Start Fast<br />Identify the Baseline<br />Align Incentives<br />Establish a repeatable approach (Program)<br />Data Flow<br />Work Flow<br />Cash Flow<br />Repeat<br />www.T-M-Partners.net<br />36<br />Better patient care costs hospitals less and improves patient outcomes.<br />Can you identify quality problems and fix them promptly?<br />Do you have the:<br />Methods<br /><ul><li>6σ, Lean, Value Stream</li></ul>Experienced People<br /><ul><li>External change agents</li></ul>Technology<br /><ul><li>Data, Workflow, Portals</li></li></ul><li>Quality is Worth It!<br />CEOs<br />Quality Scores of You and Your Competition<br />CFOs<br />Cost of Bad Quality<br />Cost of Compliance & Reporting<br />COO, CNO<br />Nurse Staffing Shortages<br />Administrative burdens<br />www.T-M-Partners.net<br />37<br />Net Profit<br />To maximize CMS Reimbursement, and your bottom line, you need to proactively identify Quality Improvement opportunities now.<br />
  49. 49. Establish Executive Priority<br />How important are Quality of Care, Core Measure Scores, and Patient Safety to the overall executive leadership?<br />How fast does the board know about the last “Never Event”?<br />Do you look at the public quality core measures of your competition?<br />In relation to the many other issues, how does this stack up?<br />What is the “Burning Platform” for this to take precedence?<br />What is it worth to improve? Budget? ROI?<br />www.T-M-Partners.net<br />38<br />Competitive Advantage<br />Patient Satisfaction<br />Budget, Cost, Compliance, Revenue, ROI<br />Best Practices, Improved Process Efficiencies<br />
  50. 50. Dr. Sunil Rao<br />A Physician’s View<br />Evidence Based Medicine = Best Practice<br />Learn and Improve<br />Benchmark Performance<br />Quality Feedback <br />On errors in real time<br />A Desire to follow proper procedure<br />Physician’s need for Core Measure data<br />In the simplest format possible <br />With easy accessibility <br />Up to date and relevant <br />www.T-M-Partners.net<br />39<br />
  51. 51. How We Get There | Performance Measurement and Public Reporting<br />Doctors and Performance Data<br />Audet AJ, Doyt MM, Shamasdin J, et al. Physicians&apos; Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund, 2005.<br />
  52. 52. How We Get There | Performance Measurement and Public Reporting<br />Doctors and Process-of-Care Data<br />Audet AJ, Doyt MM, Shamasdin J, et al. Physicians&apos; Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund, 2005.<br />
  53. 53. How We Get There | Performance Measurement and Public Reporting<br />Doctors and Clinical Outcomes Data<br />Audet AJ, Doyt MM, Shamasdin J, et al. Physicians&apos; Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund, 2005.<br />
  54. 54. How We Get There | Performance Measurement and Public Reporting<br />Doctors and Quality Data<br />Audet AJ, Doyt MM, Shamasdin J, et al. Physicians&apos; Views on Quality of Care: Findings from the Commonwealth Fund National Survey of Physicians and Quality of Care. New York: The Commonwealth Fund, 2005.<br />
  55. 55. Flash Poll<br />Is there a CEO or Board Level mandate to improve Quality?<br />Does this relate to Core Measure scores or your reporting process?<br />www.T-M-Partners.net<br />44<br />
  56. 56. How We Get There | Performance Measurement and Public Reporting<br />Improving Health Plan Performance with Public Reporting<br />Health plans that willingly allow public reporting perform at a higher level than those that choose not to do so. <br />In 2006, publicly reporting health plans outperformed non-publicly reporting plans on 37 of 40 measures. <br />The State of Health Care Quality 2007. Washington: National Committee for Quality Assurance, 2007. (No authors given.)<br />
  57. 57. Quality Reporting<br />National IT Coordinator David Blumenthal, MD, emphasized that quality measures are at the heart of his office’s strategy for using IT to transform the U.S. healthcare system<br />“The key to Meaningful use is to know how to measure for performance and to be able to give feedback to providers”<br />“just the act of measuring will continually cause us to improve”<br />“Providing better information is the foundation for change”<br />A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology at a National Quality Forum<br />www.T-M-Partners.net<br />46<br />
  58. 58. www.T-M-Partners.net<br />ImprovingProcess<br /><ul><li>Real Time Analysis
  59. 59. Real Time Alerts
  60. 60. Trending Reports
  61. 61. Rapid Changes to process of care
  62. 62. More people involved
  63. 63. Access to useful real time data
  64. 64. Incentives for change </li></ul>Moving from Reporting to Quality Management<br />How does your Quality process stack up?<br />Retrospective Review of Quality Data?<br />Concurrent Review of Core Measures?<br />Ability to drill down and analyze Core Data?<br />Process changes easily deployed?<br />Strategic Quality Goals being met?<br />Financial<br />Impact<br /><ul><li>Patient Satisfaction
  65. 65. Core Measure Scores
  66. 66. Efficient Reporting
  67. 67. Pay for Performance
  68. 68. Competitive</li></ul>Advantage<br />Concurrent<br />Analysis:<br /><ul><li>Timeliness of Data
  69. 69. Usefulness of Data
  70. 70. Extend to include
  71. 71. More Core Measures
  72. 72. More Reports
  73. 73. Include more people</li></ul>Efficient<br />Better Data<br />Real Time Access<br />Workflow<br />Notifications<br />Reporting<br />Manual<br />Meet Minimum<br />Late<br />Staff Limited<br />Level 4<br />Level 5<br />Level 3<br />Level 2<br />Level 1<br />47<br />
  74. 74. Return On Investment <br />Cost of Compliance = $500K+<br />FTEs for growing requirements<br />Cost of training and change<br />Buying EHR/IT <br />Risk = $ Millions<br />4% of Annual Payment (P4R + P4P)<br />Cost of Uncompensated Care, Poor Quality<br />Risk of being Slow or Late to Move<br />Quality Benefits = Priceless<br />ARRA/MU Incentive, CMS Bonus<br />Real-Time Visibility of Quality Measures<br />Competitive Advantage (Hospital Compare)<br />Patient And Employee Satisfaction<br />www.T-M-Partners.net<br />48<br />ROI = 5x<br /> Data Flow <br />+ Work Flow<br />= Cash Flow<br />
  75. 75. Sample ROI Model<br />www.T-M-Partners.net<br />49<br />
  76. 76. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />50<br />
  77. 77. How do you move forward?Some things you will need<br />Methodologies for solving problems<br />Executive Workout, Assessments<br />Six Sigma, Lean, Continuous Improvement<br />Requirements Definition, Program/Project Leadership<br />Additional Resources<br />Add Capacity to deliver multiple projects<br />Dedicated and Experienced Team<br />Standard Technology Platforms<br />Complementary to existing and planned platforms<br />Any Real Time Data, Any Hospital Process or Measure<br />www.T-M-Partners.net<br />51<br />Your Success<br />
  78. 78. Assess your current situation<br />How well are you reporting CMS Core Measures?<br />Are the scores as high as possible? <br />How do you plan to improve them?<br />Do you have real time quality measures for action?<br />What other quality measure or process is more important right now?<br />Executive Quality Dashboards in need?<br />www.T-M-Partners.net<br />52<br />It is up to every hospital to Analyze their specific measures, Improve the quality of care processes that these measures represent and Control the processes onward so as to ensure quality of care. <br />
  79. 79. CMS, You and Six Sigma<br />www.T-M-Partners.net<br />53<br />CMS continues to Define and Measure<br />It is up to you to Analyze the Data, Improve your Quality of Care Processes, and Control IT<br />
  80. 80. CMS ComplianceMore important than ever before…<br />www.T-M-Partners.net<br />54<br />Define<br />Cost of Compliance<br />Measure<br />Changes and mounting requirements = Unfunded Mandates<br />“Meets minimum is not enough”<br />CMS Core Measure Reporting Process<br />Approaching over 100 required reports of clinical quality<br />Abstraction From Many Sources<br />Manual Data = Error<br />Time & Cost of Each Report<br />
  81. 81. Its Not Just sending data<br />www.T-M-Partners.net<br />55<br />Analyze<br />The tracking and reporting of Core Measure performance is a huge amount of work which occupies multiple clinical staff members<br /><ul><li>Data is 3 months old
  82. 82. Vendors don’t help with abstraction
  83. 83. No Reuse of Quality Data
  84. 84. Multiple Reports = Multiple Abstractions</li></ul>Reporting Data does NOT improve Quality<br />
  85. 85. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />56<br />
  86. 86. Flash Poll<br />Are you buying a large new HIS appliction to solve all your issues? (Rip & Replace)<br />We will not even touch on EHR Systems <br />Do you have access to Real Time Quality Data?<br />We will address how you can get to more data and use it<br />Do you want to make better use of exisiting IT applications?<br />We can discuss Composite Healthcare Applications<br />Complementary to existing application investments<br />www.T-M-Partners.net<br />57<br />
  87. 87. Applying Technology to Obtain Benefits<br />www.T-M-Partners.net<br />58<br />Data Flow<br />Work Flow<br />Cash Flow<br />Analyze<br /><ul><li>Real-Time Quality Measures for Improvement
  88. 88. Get Data from Any System
  89. 89. Populate Any Form or Dashboard
  90. 90. Reduce Cost of Data Abstraction
  91. 91. Improving Processes
  92. 92. Eliminate Administrative Tasks
  93. 93. Reduce Task and Process Times
  94. 94. Notify, Escalate, Manage by Exception
  95. 95. Increase Net Income
  96. 96. Reduce Uncompensated Care
  97. 97. Reduce the Cost of Compliance
  98. 98. Improve Quality, Satisfaction, Profits</li></ul>Improve<br />Control<br />
  99. 99. Quality Management Functions<br />Real Time Quality Data<br />Abstraction<br />Workflow Processes<br />Notification and Control<br />Quality Dashboards<br />Management Platform<br />Alerts, Reports, Charts, KPIs, Never Events<br />www.T-M-Partners.net<br />59<br />Quality DBMS<br />(PN, AMI, SCIP, HF, OP)<br />
  100. 100. CNO Executive Dashboard<br />Board of Directors Report<br />Concurrent Review<br />Drill Down<br />www.T-M-Partners.net<br />60<br />
  101. 101. Quality Database<br />Quality Reports<br />Charts<br />Benchmark Data<br />
  102. 102. Abstraction & ReportingWorkflow<br />Data Drop Starts Workflow<br />Data is checked against Rule Sets<br />Processes Launched<br />Tasks Assigned<br />QI Staff Notified<br />Alerts<br />
  103. 103. Quality Reporting<br />CMS Quality Reports<br />PN<br />HF<br />AMI<br />SCIP<br />OP<br />Extendable<br />Meaningful Use<br />JCAHO<br />HB 197<br />Any Report<br />
  104. 104. Business Intelligence (BI) inPortal Solutions for Health <br />Business Intelligence provides health professionals with the tools to: <br /><ul><li>Easily analyze data and see trends
  105. 105. Make well-informed decisions
  106. 106. Create, publish, and share reports
  107. 107. Provide insight into operational, clinical, and financial data with scorecards and dashboards</li></ul> BI can help simplify the integration of information from clinical and line-of-business systems, with personalized views for caregivers, staff, and administrators. <br />
  108. 108. Technology StrategySummary<br />www.T-M-Partners.net<br />65<br />Real Time Quality Data and other Technology can help you improve Quality of Care at your Hospital.<br />It is up to you to Analyze the Data, Improve your Quality of Care Processes.<br />
  109. 109. Agenda<br />What is Quality in Healthcare?<br />Why is Quality so Important?<br />Executive Buy-in<br />Methodologies<br />Technologies<br />Q&A<br />www.T-M-Partners.net<br />66<br />
  110. 110. Quality Roadmap<br />www.T-M-Partners.net<br />67<br />

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