ATC170913: Report of the Portfolio Committee on Health on oversight visit to Gauteng Province from the 22- 23 September 2016, dated 13 September 2017
Report of the Portfolio Committee on Health on oversight visit to Gauteng Province from the 22- 23 September 2016, dated 13 September 2017.
The Portfolio Committee on Health having undertaken an oversight visit in Gauteng Province from 22 - 23 September 2016, report as follows:
One of the functions of the Portfolio Committee on Health is to conduct oversight over the Department of Health and its entities. The Committee conducted its oversight visit in Gauteng Province from 22 to 23 September 2016. The purpose of the visit was to assess progress and challenges in Tshwane District one of the National Health Insurance (NHI) pilot districts.
A decision was taken in 2010 to pilot the NHI in ten pilot districts. The pilot districts are a mixture of districts based on their economic status, diseases burden and the performance of health districts. The NHI piloting is based on investing in infrastructure development and maintenance; contracting of general practitioners (GPs) to work in primary health care facilities; and re-engineering of primary healthcare system (which will be delivered through three streams namely: school health programme, municipal ward-based outreach teams and ensuring the quality of health services.
The delegation comprised of the following Members of Parliament:
- Ms ML Dunjwa (ANC and the Chairperson of the Committee)
- Mr AF Mahlalela (ANC)
- Dr P Maesela (ANC)
- Ms CN Ncube Ndaba (ANC)
- Dr HC Volmink (DA)
- Ms LV James (DA)
The following Parliamentary Officials accompanied the delegation:
- Ms Vuyokazi Majalamba (Committee Secretary)
- Ms Lindokuhle Ngomane (Content Advisor)
- Mr Moses Mncwabe (Committee Researcher)
- Ms. Yoliswa Landu (Principal Communications Officer)
- Ms. Nombali Magubane (Committee Assistant)
The following officials from the National Department of Health accompanied the delegation
- Mr Johannes Kgatla (Acting Chief of Staff in the Office of the Minister)
- Mr Moremi Nkosi (Technical Advisor: National Health Insurance Policy)
- Mr Christie Engelbrecht (Chief Director: Infrastructure)
- Site Visited
The Committee visited the following facilities:
- Tshwane District Hospital (TDH);
- Holani Clinic;
- Stanza Bopape Community Health Centre (CHC);
- KT Motubatse Clinic; and
- Soshanguve Block TT Clinic.
3.1. Tshwane District Hospital
On 22 September 2016, the Committee conducted its oversight visit at Tshwane District Hospital, and it met the following delegation at the hospital:
- Dr N Soe (Chief Executive Officer for Tshwane District Hospital)
- Dr SS Nkusi (Clinical Manager)
- Mrs DS Motllhaga (Nursing Manager)
- Mr Mothomane Pitsi (Chief Director Tshwane District)
- Mrs Kgaugelo Marokane (Supply Chain Management)
- Mrs S Matube (Human Resources Practitioner)
- Mrs Nosubusiso Motsepe (Environmental Health Practitioner)
- Mrs Adelaide Lewis (Assistant Director: Administration and Logistics)
- Ms Khanyisile Mlangeni (Infection Control Nurse)
- Mr PH O’Ryan (Finance Manager)
- Mr CW Hanywega (Facility Management Unit Manager)
- Mrs Dimakatso Seboka (Quality Assurance Coordinator)
- Mr GP Strydom (Assets and Security Practitioner)
- Mr Elgy Khoza (Labour Relations Practitioner)
- Ms Lorraine Malebo (Director: Corporate Services)
- Mrs L Komane (Deputy Director: Health and Outreach Programme)
- Mr Ray Vuyo Mabope (Technical Advisor)
- Ms Omphemetse Mokgatlhe (Technical Assistant: Primary Health Care)
Dr Soe (CEO for Tshwane District Hospital) presented the profile of Tshwane District Hospital. He informed the Committee that Tshwane District Hospital is located in sub-district three, with an estimated catchment population of about 402 980. The hospital was opened in 2006 with only 103 beds and to date has 205 approved active beds including five beds at the maternity waiting home.
There are 13 clinics referring to Tshwane District Hospital and the hospital refers to Steve Biko Academic Hospital. The hospital provides 24 hour services which include general medicine ward, general surgery, gynaecology ward and paediatric ward, maternity and post-natal ward, kangaroo mother care ward, maternity waiting home and radiology (X-Ray). The outpatient department is opened on Mondays to Fridays from 07:00-16:00. Other services that are offered at the facility include physiotherapy, speech and audiology, occupational therapy, social worker, psychology and dietetics or food services. The CEO mentioned that Tshwane District Hospital aims to be a one stop district health service provider and that is providing all services according to the district health service package.
On drug supply processes, the CEO informed the Committee that procurement of antiviral therapy (ART) and other pharmaceutical drugs was done at Auckland Park Medical Supplies Depot. The facility has successfully implemented the fixed dose combination (FDC). The CEO further noted that with the assistance of the National Department of Health (NDOH) the pharmacy has successfully implemented the Rx Solutions which is a drug management software program. He further highlighted that Rx Solutions dispensing program was also underway and its aim was to reduce patient waiting time. The facility is one of 18 hospitals in the province where the Rational Drug Management (RDM) system was already installed. This is an electronic system used to place orders from the Auckland Park Medical Depot. The CEO further noted that to improve efficiency of drug access, the hospital is receiving prescriptions and packaging medication for three old age homes (Huis Davidtz, Huis Vergenoeg and Phillip Robertson) in the referral area.
The facility is also offering Central Chronic Medicine Dispensing and Distribution programme (CCMDD). This means that stable patients that comply with standard treatment guidelines are able to collect their medicine at a pick-up point that is accessible to them. This affords shorter travelling and queuing time for patients. To date, 996 patients from the hospital have been rolled out on the CCMDD programme.
The CEO reported to the Committee that the National Health Laboratory Services (NHLS) has been offering blood services to hospital since 2001. The national tests turnaround time is 24 hours, however, an agreement between the NHLS and the hospital for routing blood results, is a maximum of four hours and emergency tests are one hour. Tshwane District Hospital and the NHLS has intranet system that allows doctors to retrieve patients’ results as soon as they are loaded on the system. Computers are therefore available in each and every patient care area.
The CEO informed the Committee that there are infrastructure projects that have been completed which include air conditioning temperature control unit in theatre, pharmacies, offices and all the patient service areas. Door locks and elbow action taps have been upgraded. New fridges in the mortuary and five beds in the maternity waiting home have been purchased.
On achievements the CEO reported that on 3 December 2014, the Member of Executive Committee (MEC) Ms Qedani Mahlangu opened the newly upgraded outpatient department (OPD) waiting area, staff gym, staff braai area, four new lifts and the new garden. Tshwane District Hospital won the best district hospital (Tshwanelo Awards 2014); 1st runner up for the best district hospital 2015; 1st runner up for the best pharmacy in 2014; winner of best pharmacy in 2015; and best performance patient satisfaction amongst district hospitals in 2015.
During March 2016, the hospital was audited by the Auditor General and there were no findings on assets and pharmacy departments.
The Committee went on a walkabout and observed the following:
The Committee noted that the hospital was very neat and the resuscitation area was fully equipped.
The Committee noted that the theatre was well kept and fully equipped.
3.1.3. Female medical ward
The Committee noticed that some officials in the ward were not wearing protective clothing. The medicine trolley was not locked which is a serious concern to the Committee as this may lead to medication being stolen.
- Neonatal unit
This is a fully equipped six-bedded unit. The Committee observed that infection control and prevention measures are being implemented as the delegation was given masks, aprons and hand sanitizer before entering the ward. The hospital reported to have had zero neonatal mortality in the past seven years.
- Occupational therapy unit
The occupational therapist informed the Committee that they see approximately four speech and 12 audio patients per day. School children with speech, or audio therapy needs are also referred by the school health programme.
- Optometry unit
The Committee also visited the optometry unit and found it to be overcrowded with a narrow waiting area.
- Admission office
The Committee observed that the patients’ particulars are captured manually upon admission and captured on the electronic system thereafter.
- Control Room (Security)
The Committee was ushered into the control room which serves as a nerve centre for safety and security in the facility. Upon the visit, the Committee was informed that the control room is manned by two officials however on the oversight visit, one personnel was off leaving the control room with one official. The Committee was pleased with the efforts made to ensure the safety and security of patients, officials and the infrastructure. It however cited concerns at the cost of security which is outsourced.
The Committee also inspected the mortuary and found that it was in a clean condition and well kept. It also noted that the records of the deceased were entered accordingly on the main mortuary register. The challenge that was mentioned was the shortage of staff in the mortuary. The official responsible for the mortuary mentioned that there are short of three more posts.
The officials working at the laundry complained about laundry shortages. They further highlighted that there were challenges with laundry provision by Masakhane laundry because they do not get the full number of items sent for laundering and sometimes they even get laundry that does not even belong to the hospital. They further complained that they were short staffed.
The Committee observed that the kitchen was very clean and well managed. The Committee was also informed that the kitchen is only responsible for preparation of breakfast for patients and receiving, storing, warming and delivering ready-made meals (lunch and dinner) to patients. The officials responsible for the kitchen mentioned that Masakhane is the Gauteng Department of Health owned and responsible for meals and laundry services at health facilities including Tshwane District Hospital. The Committee was informed that some of the Psychiatric patients have complained about the small quantity of meals they are served.
- Cleaning Services
Amongst the sections visited by the Committee was the Cleaning Department Store, which serves as a storeroom and cleaners quarters. Though this section (Cleaning Department Store) is close to the area under renovation, the Committee observed that it was untidy. Upon talking to the supervisor responsible for this area, the Committee recommended closer support to ensure that cleanliness is adhered to. Though, the Committee was informed of the shortage of cleaning staff in this section, it was unhappy with the dirtiness that it observed.
There are two new generators that are well kept and secured. They are checked every Friday.
- Holani Clinic
The Committee met with the following delegation:
- Mr NJ Nconco (Area Manager: Primary Health Care)
- Dr Molapane K Chueu (Public Health Medicine Specialist)
- Ms Julia Aphane (Area Manager)
- Ms Mmapula Mmurwa (Facility Manager)
- Mr SS Skhosana (Chairperson: Clinic Committee)
- Mr BF Mdala (Clinic Committee Member)
- Mr HG Mahlangu (Clinic Committee Member)
- Mr R R Makama (Secretary: Clinic Committee)
Ms Mmruwa made a presentation to the Committee and noted that the facility serves a catchment population of 48 587 with an average of 4500 patients per month. Operating hours are from 7:30-17:30 weekdays. Services that are offered by the facility include chronic, acute illnesses and mother and child wellness. The facility refers to Stanza Bopape CHC and surrounding Non-Governmental Organisations (NGOs).
On Ideal Clinic status, Ms Mmuruwa reported that assessments were done in May and August 2016. The overall performance improved from 86% in May to 89% in August. The clinic achieved gold status. Elements to improve on are; availability of provincial and national policies, staffing in correspondence to WISN results and training of staff on Integrated Management of Childhood Illness and Basic Life Support.
Achievements for the clinic were as follows:
- There is a ward-based outreach team (WBOT) attached to the clinic. Administers Vitamin A and deworming children in the community.
- The clinics conducts campaigns as per identified challenges within communities.
- The clinic is attached to Stanza Bopape CHC for school health services.
- The Human Papillomavirus (HPV) was conducted by the facility in January and again in August 2016.
- Installation and commissioning of the National Department of Health (NDOH) donated prefabricated six room structure has been done.
The following were highlighted as challenges:
- Inconsistency in administration of Vitamin A and feedback to facility by the ward-based outreach team.
- Poor attendance of facility meetings by ward-based outreach team.
- Irregular visits to households for home based care.
- There is only one doctor at the facility.
- There is a lack of space and the filing room is very small.
On CCMDD, Ms Mmurwa noted that the target for enrolment of patients for CCMDD was at 1068 and the number of patients enrolled in August 2016 was 505. Fifteen patients collect their medication at external pick-up points. There are two other external pick up points around the catchment area, namely; Dr Ndlovu at Tsamaya road and Mamelodi Pharmacy.
Interventions to address challenges were as follows:
- Challenges on WBOT were communicated to the team leader and area manager.
- Meetings have been held with the Facility Management Unit (FMU) and Department of Infrastructure Development (DID).
- Irregular visits by district clinical specialist team (DCST) has been reported to the area manager.
- The six roomed park home from the NDoH will relieve the space challenges.
The Committee had a walkabout and noted that the space challenges.
- Stanza Bopape CHC
The Committee met with the following delegation at the facility:
- Mrs Nomgqibelo Patricia Nogxina (Operational Manager)
- Mrs DM Tladi (Professional Nurse)
- Ms BM Goba (Clinical Nurse Practitioner: Casualty)
- Mr Sidney Mako (Assistant Director: Communications)
- Ms Tsoro Mokhopa (Deputy Director: Human Resources Manager)
- Mr Wilfred Rampou (Clinic Committee)
- Ms Francinah Moshidi (Clinic Committee)
- Mr Samuel Maila (Clinic Committee)
- Mr Abram Mtshweni (Clinic Committee)
The Committee went on a walkabout and noted the following:
- Emergency unit
The doctor working at the unit informed the Committee that there are security risks at the centre especially at this particular unit following an incident of physical assault of one doctor whilst on duty. She further reported that they are struggling to secure supplies and equipment such as suturing materials and ECG machines. The Committee noted the lack of privacy curtains in the unit.
- Filing room
The Committee noted the insufficient space for patient files.
- Maternity unit
The unit manager noted that there is no hot water at the unit as the geysers are not working. The Committee noticed that the health care workers are using the medicines fridge for their food as there is no additional fridge.
The pharmacist informed the Committee that stock at the pharmacy was closely monitored and stock taking was done twice a day. This was done to keep track of stock so that an order is placed on time. This also enables the facility to keep track of medicine expiry dates.
The storeroom was well kept, full of stock and properly labelled. The pharmacist informed the Committee that the facility seldom run of stock and when they do, they borrow from Mamelodi Hospital.
- Consultation room
The Committee was informed that the Blood Pressure (BP) machines were not working since January and had to use the portable ones. The computers were also not functioning during the Committee’s visit.
- Feedback meeting
Ms Otsheleng briefed the Committee and provided the Committee with the facility profile. The facility was established to cater for the increasing health needs of communities on the Eastern side of Mamelodi. Stanza Bopape CHC was built by the municipality in conjunction with the University of Pretoria and subsequently handed over to the Provincial Department of Health in 1998. The facility is surrounded by informal settlements on the East and North of Tsamaya Road and formal houses on the South and Western sides. According to the 2016 District Health Information System (DHIS), Stanza Bopape CHC serves a catchment population of 221 136. The population is increasing at a rapid rate due to movement of people in and around the clinic’s catchment area and the rapid development of informal settlements around the area.
The CHC offer services 24 hours and seven days a week including public holidays and weekends. The facility offers a full package of services namely:
- Non-communicable diseases (hypertension, diabetes mellitus, asthma and arthritis);
- HIV/AIDS, STIs and TB (HAST) services (TB, HIV, Prevention of mother to child transmission and ART drugs);
- Reproductive health (antenatal health services and postnatal services);
- Immunization and minor ailments;
- Oral and dental health services, rehabilitation services, mental health and child psychiatry and psychological services;
- Maternity services and emergency or casualty services;
- Medico-legal services (Thuthuzela care centre attached to Mamelodi Hospital);
- Outreach services (school health services and home based care);
On Ideal Clinic status, the facility was at 80% in April 2016 and achieved 89% in August 2016 (gold status).
The following were highlighted as achievements:
- There is a WBOT attached to the clinic. The team is responsible for household profiling; identification of pregnant mothers and refer them for early booking; assist in doing DOTS for patients on TB treatment; trace TB defaulters; give Vitamin A; deworm children; identify and refer community members for other services like social worker; and conduct campaigns as per identified challenges within the community.
- The DSCT periodically pays support visits to the clinic. The team assesses the quality of services provided at priority health programmes such as antenatal care, Integrated Management of Childhood Illness and EPI. They do in-service training for staff and also assist with the provision of guidelines.
- There are two school health team attached to the facility comprises of a professional nurse and enrolled nursing assistant. Both teams have been involved in the HPV campaign at schools in the catchment area.
- The facility is in the process of replacing gutters and down pipes.
- Upgrading of the security guardhouse lighting.
- Installation and commissioning of alternative water supply line to the park home.
Challenges facing the facility were indicated as follows:
- Community health workers were on strike during the Committee’s visit.
- The facility is awaiting implementation of external renovations and the City of Tshwane’s approval for additional land to extend the CHC.
- The Clinic Committee informed the Committee that they were concerned about the staff shortages at the facility.
On CCMDD, Mr Otsheleng reported that there is one internal pick-up puck manned by Laser with 6028 clients on the programme.
- Soshanguve Block TT Clinic
On arrival the Committee had a walkabout at the facility. The facility was overcrowded with patients waiting at outdoor waiting area. This was a concern because the one part of the waiting area was not covered for weather conditions.
- Consultation room
The Committee noticed that files were scattered in consultation room. Drugs were found to be lying around and not kept in a locked storage.
Medication was properly packed and fully labelled.
The Committee had a feedback meeting as follows:
Ms Leroke briefed the Committee and noted that Soshanguve Block TT Clinic is located on the corner of M17 and M20 road in the Southern side of Soshanguve, approximately 38 km from Pretoria. It has a catchment population of 43 848 according to the 2016 mid-year population estimates.
On Ideal Clinic status, the facility did not achieve any status for 2016. Challenges for not achieving the status were due to the unavailability of defibrillator, Pulse Oximeter with paediatric and adult probes, adjustable chair in the emergency room, some surgical supplies, instruments that are needed to stitch, delivery packs, no filing cabinets in the filing room with files stored in boxes on the floor.
Achievements for the facility were highlighted as follows:
- Availability of maternal, child and women’s health (MCWH) protocols
- On-site training
- There is a school health team attached to the facility. The facility receives data from the team on alternate months as the team also serves other facilities
- There is a smooth referral system and feedback between the facility and the team
- Extractor fan installed for TB room
- Filing room extended even though it is still small
- Disability rails and ramps installed
- Installation of additional parking shelters for staff
- Installation of patient waiting shelter
- Laboratory services for HIV tests
- Provision of ARVs to the patients
The following were highlighted as challenges facing the facility:
- Staff shortages
- Unavailability of some surgical items and equipment
- There is currently no WBOT attached to the facility
- No scheduled regular visits by the DCST
- School health team not dedicated to the facility only
- Infrastructure problem is that the facility is small
- External pick-up points (PUP) for CCMDD patients is not satisfactory
The following were indicated as interventions:
- Interviews have been conducted for professional nurses and awaiting appointments
- Follow-up to be done weekly for procurement of surgical items and equipment
- DCST visits to the facility to be scheduled regularly
- School health team to be available for each facility
- Facility to be extended to accommodate support services like rehabilitation, boardroom etc.
- Local private doctors to be enrolled as PUP
- Decanting of the facilities through the NGOs
In her concluding remarks, Ms Leroke informed the Committee that the facility will be ideal by March 2017. Staff will be assisted in addressing the challenges so that the facility can attain an Ideal status.
- KT Motubatse Clinic
The Committee met with the same delegation met with at Soshanguve Block TT Clinic:
On arrival the Committee had a walkabout at the facility and noted that there were long queues at casualty. Clients complained that they had to wait for approximately eight hours before they get attended.
Ms Leroke made the presentation to the Committee and noted that KT Motubatse Clinic is situated in the northern part of Pretoria, about 35 km from the city. It serves a population of 75 710 with 5434 of its population being children under five years of age. A total of 55 571 of the population is uninsured.
On Ideal Clinic status, Ms Leroke informed the Committee that the clinic achieved gold status in August 2016.
The following were highlighted as achievements:
- There is a WBOT attached to the clinic.
- The team assists in conducting DOTS for TB patients and tracing of defaulters
- They administer Vitamin A and deworming agent to children in the community
- The team identifies and refer community members for other services like social worker, etc.
- The team periodically pays support visits to the clinic.
- The team assesses the quality of services provided by health programmes such as antenatal care, IMCE and EPI.
- The team also conducts on spot interventions where there are deviations.
- They offer in service training to staff.
- Assist in provision of clinical guidelines.
On integrated school health programme (ISHP) the following were reported as achievements:
- The team identifies and refer children suspected of physical, emotional, sexual abuse and neglect.
- Assess the nutritional status of children and their eating habits and intervene when there is a need.
- Immunizes children against tetanus and deworm as well.
- Compile monthly performance data.
The following were highlighted as infrastructure achievements:
- Waterproofing of the flat roofs on the B-Block completed.
- Installation of the blinds in various service areas.
- Designed plan for extension of facility into a CHC is approved.
In relation to the WBOTs, DCST and ISHP the following challenges were reported:
- The facility has one WBOT, consisting of nine community health care workers and the catchment area is too big to be covered by one team.
- The introduction of Smart Purse resulted in 33 community health workers not being absorbed.
- On ISHP, the team is not specifically dedicated to KT Motubatse (also serving other facilities).
- Still awaiting the finalisation of upgrading of the water tank.
- Awaiting implementation of the proposed plan to upgrade the clinic to a CHC.
- Delays in response time to day to day maintenance work.
- Delays in completion of the branding project.
- Meeting with the Member of the Executive Committee (MEC)
Having concluded its oversight in Gauteng, the Committee had a feedback meeting with the MEC and raised major issues that are in the report.
- Findings per facility
- Tshwane District Hospital
- There are linen shortages at the facility as Masakhane does not return all the linen that went in. Masakhane is not meeting the needs of the hospital.
- The Committee was concerned about the poor quality of food
- There are staff shortages at the facility across all categories.
- There are high patient volume leading to long waiting times.
- Stanza Bopape CHC
- There are staff shortages at across all categories. There is only one radiographer for the facility; this leaves the facility with no staff at the X-Ray department after hours.
- The emergency unit is not fully equipped and usually experience a shortage of supplies.
- The Committee observed the lack of privacy curtains and poor lighting at casualty.
- The geysers were not functioning at the maternity ward.
- BP machines and computers in some units of the facility were not functioning.
- There is poor turnaround time for maintenance and replacement of equipment.
- Record keeping is a challenge due to lack of storage space.
- Safety and security was found to be inadequate.
- Poor quality of linen.
- Holani Clinic
- There are staff shortages at the facility.
- Patient waiting time is long.
- Ambulance response time is long, taking up to three hours.
- There are space constraints particularly the filing room.
- Soshanguve Block TT Clinic
- There is no proper filing system at the facility as well as lack of space for the safe-keeping of patient files which may lead to misfiling and loss of records.
- Patients wait long for their medication.
- The facility is also servicing patients from North West which also contributes to the long queues.
- The clinic has not met the Ideal Clinic status due to unavailability of equipment.
- The waiting area cannot accommodate all patients. Patients had to line up outside.
- KT Motubatse Clinic
- The facility is faced with a shortage of linen. The facility reported that they experience challenges with linen returns from Masakhane.
- There is high patient volume leading to long waiting times.
- There is a general lack of space.
- There is no shelter for waiting queuing patients.
6. Overall findings and observations
The Committee made the following findings and observations:
- Human resources
The provincial department suffers from staff shortages across all categories. This in turn leads to long patient waiting times. The Committee observed that in all the clinics visited there were doctors contracted under NHI which is commendable.
There was a general lack of space at the clinics visited, with Holani Clinic being the most affected.
Some facilities reported on the long turnaround times for maintenance and replacement of equipment.
Linen and food supply is centralised at Masakhane. The facilities visited reported challenges in relation to the supply of linen and the quality of food, provided by Masakhane. The Committee questioned whether the facility has the capacity to render these services. Procurement of medical supplies is a challenge for most of the clinics.
- Governance structures
In most of the health facilities visited, governance structures do exist and have a good relationship with the health facilities.
- PHC re-engineering
Ward-based outreach teams are not fully functional due to a strike action by community health workers, this in turn impacts on the provision of home-based care.
School health programme, the district has 20 teams which are attached to health facilities. There is one roving district clinical specialist team that supports the facilities in the districts.
- Emergency Medical Services
Ambulance response time is long, taking over three hours or longer.
The Gauteng Department of Health should:
- Ensure that priority health personnel vacancies are filled, as well as the recruitment and retention of health professionals.
- Address the shortage of space in worst affected clinics by constructing a new structure or providing a park home as a temporary measure.
- Ensure that provincial officials conform to supply chain management policies in improving procurement turn-around time.
- Pay close attention to Masakhane to ensure that the critical service it provides to health facilities does not compromise service delivery.
- Ensure that clinic committees and hospital Boards are fully functional.
- Ensure the strengthening of primary health care programmes particularly addressing the issues around CHWs who are part of the ward-based outreach teams.
- Improve medical record keeping so as to ensure easy retrieval of records and contribute to decrease in patient waiting time.
- Ensure access to emergency care by improving emergency medical services response time in order to improve patient outcomes.
Report to be considered.
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