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Learning Session 6. National Waiting Times Centre Board Golden Jubilee National Hospital. Where are you with respect the programme goals and process reliability?. Seen statistically significant improvement but haven’t yet met goals of demonstrated reliability Examples

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Learning Session 6

National Waiting Times Centre BoardGolden Jubilee National Hospital

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Where are you with respect the programme goals and process reliability?

  • Seen statistically significant improvement but haven’t yet met goals of demonstrated reliability


  • GTT & Leadership walkrounds

  • On Time Antibiotics & Surgical Pause

  • Safety Briefs, Hand Hygiene & C. Diff rates

  • CV Bundles

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Leadership Walkrounds reliability?

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Global Trigger Tool reliability?

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On Time Antibiotics reliability?

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PeriOp Briefings reliability?

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Safety Briefings reliability?

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Hand Hygiene reliability?

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CV Bundle Compliance reliability?

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Our Success reliability?

Success 1 (MM)

INR Reporting

Success 3 (Peri Op)

Surgical Pause

  • Success 2 (GW)

  • Safety Briefs

  • Success 4 (Leadership)

  • Leadership Walkrounds

Success 5 (Critical Care)

CV Bundles

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Our Challenges reliability?

CVL-BSI rate – improvement in rate, yet to achieve 100 days between

VAP rate – no significant improvement in rate


Outreach team

Multi Disciplinary Engagement

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Barriers and Challenges. reliability?

  • Tendency on occasion to spread too quickly without ensuring reliable process in place.

  • Further development required to ‘mature’ measurement strategy.

  • Elements of recovery need to be fully tested in coming months.

  • Medical Engagement improving and further education and support will help further.

  • Continue to build capacity and integrate SPSP into our overall approach to quality.

  • Fully embed across the Board.

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What we’re trying.. reliability?

  • Local Health Board Coordinator (LHBC) has undertaken a hands on approach to programme management.

    • One year pilot – started Feb 1st 2010 – omens are good!

  • Extranet Data set has been fully reviewed and updated

  • Local data management strategy is being improved with increased responsibility to team leads for data management.

  • The effectiveness of the SPSP steering group is being reviewed including:

    • Role of Exec Directors.

    • Role of team leads.

    • The use of data – how we report it and use it more effectively.

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Ongoing work…. reliability?

  • Raising SPSP profile across Board through formal governance structures.

  • Extranet doesn’t tell the whole story- Adoption of the ‘SPSP way’ is becoming more common – e.g.

    • Improved very high incident reporting process

    • Involvement of Lay people - walk rounds.

    • PDSA becoming less of a ‘mystery’

    • At the heart of our approach to adoption of the quality strategy

    • Introduction of Electronic handover tool.

    • Reflected in NHS QIS CGRM feedback.

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Perioperative Workstream Team Members Attending reliability?

Helen Kerrigan – Team Lead, SCN

Rosie McGuire- Anaesthetic Nurse

Alan Wilson- General Team Leader

Lorna Morrisson – Orthopaedic Scrub Nurse

Shona Patterson – Clinical leader- Anaes/Pacu

Bernadette Brady- Recovery Nurse


Carl Hope- General Manager- Surgical services

XX – Consultant Orthopaedic Surgeon

National Waiting Times Centre Board

Golden Jubilee National Hospital

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Scottish Patient Safety Programme Peri op Current Work: reliability?

Drivers and Changes

Secondary Drivers

Primary Drivers


Process Changes

Antibiotic Protocol in place and implemented in all areas

Provide appropriate reliable and timely care to patients to prevent SSI

  • Ensure proper prescribing of prophylactic Antibiotics.

  • Avoid hair removal if possible – do not use razor.

  • Maintain normal blood glucose

  • Ensure normal body temperature.

  • Undergo team training

  • Use briefings

  • DVT Prophylaxis

  • Continuation of beta blockers

Policy developed and testing commenced

Testing in endoscopy theatres

Improved peri-operative outcomes

(Reduced peri-operative adverse incidents, infections and cardiovascular events

Create a team culture attuned to detecting and rectifying intra operative errors.

Testing in general theatres

Human factors and MDT patient safety training taking place monthly

Surgical pause implemented in all areas.

Prevent Peri operative cardiovascular events.

DVT Prophylaxis implemented in all areas

Beta Blockade testing in ophthalmic theatres

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Peri Operative Secondary Driver: reliability?Prophylactic Antibiotics


DATA FEEDBACK TO FRONTLINE STAFF: 1.VAP Rate 2. Percent Compliance VAP Bundle (segmented) 3. Percent compliance with Daily Goals




















Ensure antibiotic has been administered within 60 minutes prior to the operation

Change 5: Pilot size expanded to Thoracic, Cardiac and General Surgery Theatres.

Change 4: Educational sessions arranged for medical and nursing staff.

Change 3: Adaptations made to protocol.

Change 2: Protocol introduced to standardise antibiotic used.

Change 1: Test commenced in Orthopedic Theatres.

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Keys to Success (Peri Op) reliability?

Change 1 – Test commenced in Orthopedic Theatres

  • Started small.

  • Deciding how to measure data

    Change 2 – Protocol Introduced

  • Overcoming the difficulty of engaging the multi-disciplinary team

  • Test often!

    Change 3 - Adaptations made to protocol

  • Much discussion and input from surgeons, anaesthetists, microbiologist and pharmacy.

  • Communicating the final protocol to all relevant staff

    Change 4 - Educational sessions arranged for medical and nursing staff.

  • Open sessions to discuss the drugs used, prescribing and administration methods.

    Change 5 –Pilot size expanded to Thoracic, Cardiac and General Surgery Theatres.

  • Corporate support for the implementation of the protocol.

  • Involving clinicians at all change tests

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Worst Bit – Peri Op reliability?

Christmas Break

Discontinuation of Bear Paws

Introduction of Bear Paws

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Best Bit – Peri -Op reliability?

New format testing in cardiac theatres

New staff not completing Pause forms

Successful spread to whole department

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Our Progress – Peri Op reliability?Improving Communication

  • Surgical Pause & Brief fully embedded in daily practice within all operating theatres

  • Different specialities have developed their own format

  • Pre-op & PACU (recovery) have modified a ‘ward’ safety brief for use in their area

  • Data being collected shows the process is reliable

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Our Progress – Peri Op reliability?Surgical Site Infection Rates

Any hair removal is by clipping only and razors have been completely removed from theatre and the wards

Data collected indicates a reliable process and supports spread

Standardised Antibiotic Prophylaxis Protocol has been produced for all surgical specialities

Data collection indicates good compliance in all areas except for general surgery

Process for achieving normothermia has undergone PDSA testing and changing for several months with little improvement and is now being tested in another specialty

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Our Progress – Peri Op reliability?Post-op Complications

Protocol for Blood glucose control has been created and PDSA testing is under way

Data collection and spread will commence within the next month

Process for DVT Prophylaxis was well established and data collection indicated good compliance

New SIGN guidelines has prompted a review of the process and PDSA retesting

This has affected compliance in this bundle

Beta-Blockade protocols are being PDSA tested in one area

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What We Have Done Well reliability?Peri Op

All theatre nursing staff and majority of medical staff are involved with SPSP (to some extent!)

Periop SPSP Meetings are well attended

Staff are much better at communicating with each other (particularly junior staff)

Improved relationships with other clinical areas and collaborative working (CVC & PVC bundles)

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What We Need To Work On reliability?Peri Op

Implementation, refinement, and spread of remaining bundles (beta-blockade, blood glucose, DVT prophylaxis and normothermia)

Investigate ways to measure tangible effects of the bundles (review and compare adverse incidents reports, review discharge documentation for evidence of post-op complications)

Increase the engagement of medical staff

Improve feed back mechanism for staff and patients

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In Summary – Peri Op reliability?

SPSP as a whole is well established in our department

We are aware of what we are doing well and what we need to work on

There have been many indirect benefits produced from the Periop SPSP

SPSP and the Productive Operating Theatre Programme will compliment each other well

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Critical Care Workstream reliability? Team Members Attending

National Waiting Times Centre Board

Golden Jubilee National Hospital

Alison Hunter – Senior Charge Nurse

Megan Bateson - Nurse

Susan Rafferty - Nurse

Mary Black - Nurse

Ken McKinlay – Consultant Anaesthetist

Carol McEwan - Nurse

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Scottish Patient Safety Programme Critical Care Current Work:

Drivers and Changes


Primary Drivers

Process Changes

Secondary Drivers

Reduce complications from


Reduce complications from


Optimal glucose control

Prevent healthcare associated

infections and cross


Proper sepsis recognition

and treatment

Reliable planning, communication and collaboration of multi disciplinary team

Preventing VAP bundle - implemented

Provide reliable, timely, care to critical care patients using evidence-based therapies

CVC insertion & maintenance bundle –


Improve Critical Care


(Reduce mortality,

infections and

other adverse events)

Daily MDT rounds

SBAR for nursing handovers

Create a

collaborative team

and safety culture

Redesigned Daily Goals

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Secondary Driver: Work: Reliable planning, communication and collaborationof multi disciplinary team


DATA FEEDBACK TO FRONTLINE STAFF: 1.VAP Rate 2. Percent Compliance VAP Bundle (segmented) 3. Percent compliance with Daily Goals





















Failed at first attempt. Redesigned, simplified,relaunched Jan 10

Change 4: Testing afternoon mini – round for Goals review/update

Change 3: Bedside nurse/team leader redundancy

Change 2: Redesign goal sheet (coloured paper format) & test 1-4-5

Change 1: Ask 5 staff how, what & when of Daily Goals

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Daily Goals- Critical Care Work:

Change 1 – Abandon and relaunch

  • Ask 5 ( or 15 ) what goals they value & how we set them

    Change 2 – Redesign & testing

  • Removed from electronic record

  • Test simplified paper format

    Change 3 – Nurses as redundancy

  • Prompting

  • Scribing (where necessary)

    Change 4 – Afternoon mini round

  • Focus on communication between consultant, team leader & bedside nurse

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What hasn’t worked …. Work: Daily Goals 1

Critical Care Workstream

  • Spreading before reliability

  • Making it too complicated

    • Too many goals

    • Electronic format

  • Using nagging as an implementation strategy

  • Presuming MDT will perceive the benefits

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Mark 1 – no PM review, no specific targets

Mark 2 – segmented for sedation break, weaning targets & PM review


Critical Care Workstream

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Where are you with respect to the programme goals and process reliability?

Critical Care Workstream

Seen statistically significant improvement but haven’t yet met goals of demonstrated reliability

CV bundles – process & outcomes

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CVL-BSI process reliability?Process & Outcomes

Insertion Bundle - approx. 90% compliance last 3 months – stable/improving

Maintenance Bundle – best performance 90% in January – now fallen to < 80%

CVL-BSI rate – shift in performance – yet to achieve goals

Critical Care Workstream

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THE BEST BIT- Critical Care process reliability?

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THE WORST BIT process reliability?Critical Care

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STAFF INFORMATION process reliability?Critical Care

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INFORMATION FOR FAMILIES process reliability?Critical Care

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OUR LEARNING process reliability?Critical Care

Testing, testing

Run, don’t walk vs. Reliable process

Quick wins build enthusiasm & confidence

Some consensus comes with time, testing & data

Real engagement needs work

Ongoing measurement

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Eleanor Lang –Lead Nurse Quality and Performance process reliability?

Jacqui Brown- Clinical Educator- orthopaedics

Susan McLaughlin – Clinical Educator- cardiothoracic

Angela Chesney – Charge Nurse

Carole Dempsey- Staff Nurse

Irene McGachy – Senior Staff Nurse

Suzanne Duffy – Staff Nurse

National Waiting Times Centre Board

Golden Jubilee National Hospital

General Ward Workstream Team Members Attending

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Scottish Patient Safety Programme General Ward Current Work:

Drivers and Changes

Primary Drivers

Secondary Drivers

Process Changes


MEWS chart – implemented in 6 in patient wards, monitoring actions taken following higher MEWs scores with senior nurses.

Early identification of patient deterioration (MEWS)-  

Early response system to

respond to deterioration

Prevent pressure ulcers

Involve patients in planning

Prevent healthcare associated infections

Reliable planning, communication and collaboration of multi disciplinary team

Provide reliable, timely, care using evidence-based therapies

Early response system – intervention algorithm implemented

Improved general

ward outcomes

(Reduced infections,

crash calls,


ulcers, AE in CHF and AMI patients)

PVC bundle- implemented in 5 wards- compliance with completing the bundle has been challenging improving

Ensure patient and family centered care

Hand Hygiene in place and embedded in all clinical areas. Amalgamating extranet report.

Create a

collaborative team

and safety culture

Safety Briefings implemented in all wards, OPD and day units. Compliance is good.

SBAR – shift handovers in place in 2 wards. Monitoring quality of handovers in 1 ward. Testing patient transfers using SBAR in HDU- wards

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Secondary Drivers: implementation of SBAR in handovers

DATA FEEDBACK TO FRONTLINE STAFF: 1.Crash Call Rate 2. Percent Compliance w EWS 3. Percent compliance with EBAR 4. Percent of patients with appropriate interventions





















SBAR chart devised and includes all relevant information in pilot population segmented type of surgery and one HDU.

Change 4: on to 6th test of form using rapid testing principles and continues with smaller segment

Change 3: redesign of chart and continued testing including staff comments

Change 2: rapid tests of redesigned SBAR handover chart completing PDSAs

Change 1: new SBAR chart devised and tested on one patient transfer form HDU to ward with Charge Nurse

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Keys to Success

Change 1 –Key senior nursing staff at monthly general ward meetings

  • General ward group meet monthly- cross directorate.

  • Support from executive lead and SPSP administrator keeps this group meeting regularly reviewing progress and challenges.

  • This group allows all staff to see what has been implemented where and plan for testing and implementation of other parts of the general ward drivers.

    Change 2- Educational sessions for nursing staff.

  • Supported by clinical educators- ongoing short training sessions for ward staff at the clinical areas where staffing allows for this.

  • Recent awareness week on SPSP general ward work help in canteen- held in April.

    Change 3 – Template introduced to reinforce use of SBAR in ward handovers during testing and implementation.

  • Template designed by ward team and reviewed and redesigned during testing phase.

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Success, Safety briefings (General Ward)

  • Using same folder in all areas

  • Encouraging all ward team to use this information

  • Dips in compliance annotated and SCN informed re taking action

  • In all general ward areas, out patients and day care areas

  • Positively received by nursing staff

  • Varying types of format in use has helped staff engagement

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In progress…General Ward

  • Starting to collect data on MEWS actions taken

  • Due to upload this data to extranet in May

  • More testing of use of SBAR for handovers and patient transfers planned

  • Continue to establish the General ward group

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In progress – General Ward

  • Starting to test and implement SBAR

  • Shift to shift handovers in place in 2 wards….spread is planned

  • Starting to measure and record quality of SBAR handovers in 1 ward- plan to start measuring quality on second ward in May

  • HDU1 to cardiothoracic ward- rapid testing of SBAR sheet in progress with HDU Charge Nurse

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Our challenges – General Ward

  • PVC bundle compliance variable in some areas

  • Testing and adapting complete

  • Performance issue

  • Low rates of infection….relevance of this difficult for staff to see.

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Challenges – General Ward

  • Keeping the momentum!

  • Keeping all relevant teams and staff updated and involved

  • Recruiting ward staff to the group meetings and ownership of the work

  • Opportunity for the team to understand what the data tells us

  • Recognition of impact of other national work streams in place at same time…..LBC, RTC

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Medicines Management Workstream Team Members

Ken Kinghorn- Chief Pharmacist } Attending

Geraldine Sale – Senior Pharmacist } Attending

Grace Kusu Orkar – Pharmacist

Gordon Adamson – Pharmacist

Gordon Rankin – Head BMS Haematology

National Waiting Times Centre Board

Golden Jubilee National Hospital

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Scottish Patient Safety Programme Medicines Management Current Work:

Drivers and Changes

Process Changes


Primary Drivers

Secondary Drivers

New gentamicin dosage policy with web based dosing advice

Use standardised protocols & algorithms for high risk medicines

Reliable MM Process

New vancomycin dosage policy with web based dosing advice

FMEA devised for warfarin therapy

Provide safe and effective medicines management

Identify high risk areas

using FMEA

FMEA being developed for gentamicin therapy

Report all high INR results

Accuracy of medicines at the interface

Continuation of care

  • Medicines Reconciliation being rolled out :

  • Orthopaedics (ongoing)

  • Cardiac Surgery (Jan 10)

  • Thoracic Surgery (April 10)

  • Cardiology (May 10)

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Cardiac Surgery- Current Work: Medicines Management

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Future Plans Current Work: Medicines Management

  • Thoracic surgery (April 10)

  • Cardiology (May 10)

  • Accuracy checking of information

  • Introduction of new:

    • Inpatient kardex

    • Discharge prescription

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High INRs Current Work: Medicines Management

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High INRs Current Work: Medicines Management

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Future Plans Current Work: Medicines Management

  • Continue to collect data

  • Analyse data to inform warfarin FMEA programme

  • Pull high INR case notes to identify

    • Critical points in process

    • Identify general and specific training needs

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Leadership Workstream Team Members Attending Current Work:

Linda McCurry – Clinical Risk Manager

Bernie McCulloch- Programme Manager SPSP

Maureen Nugent – Dietetic Manager

National Waiting Times Centre Board

Golden Jubilee National Hospital

Others Attending

Salem Haj-Yahia - Consultant Cardiac Surgeon

Anne Marie Cavanagh – Senior Nurse Manager

Jayne Henry – Nurse Manager

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Scottish Patient Safety Programme Leadership - Current Work:

Drivers and Changes

Secondary Drivers

Process Changes


Primary Drivers

Steering/ Implementation group to support staff, focus activity,track progress and remove barriers.

Data measurement system that supports understanding of patient safety goals and outcomes.

Executive sponsorship.

Progress monitored across all streams through spread map.

SPSP on Senior Management and Board Agenda’s

Leadership walk rounds in place that involve senior team and feedback data to staff. .

SPSP Steering Group oversees all SPSP activity.

Develop infrastructure to support safety and improvement which ensures oversight to all stakeholders.

GTT process in place aligned to RM arrangements.

Data management system in place – work streams gaining more ownership of data by teams uploading data onto extranet

SPSP activity will be fully supported by Senior Leaders and Integrated into the quality and safety structure of the Board.

Walk rounds fully established.

Data management and supporting processes improving.

Promote the position of quality in the Board .

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Leadership Secondary Driver: Establish Patient Safety Walk rounds across all appropriate areas.


DATA FEEDBACK TO FRONTLINE STAFF: 1.VAP Rate 2. Percent Compliance VAP Bundle (segmented) 3. Percent compliance with Daily Goals




















Process in place that ensures that walk rounds occur on a regular basis which involve staff and generate actions outcomes of which are fed back to frontline staff

Change 5: Greater involvement from Directorate and Local Managers after visit has occurred to ensure actions are not duplicated.

Change 4: Support and administrative processes improved to ensure accurate data collection and management of actions.

Change 3: Data managed through Datix risk management software.

Change 2: Walk rounds expanded to include all Executive Directors.

Change 1: Walk rounds introduced. Limited involvement from Exec team.

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Help Needed Please!

Perioperative: Normothermia - many patients have a normal temp below 36oC with no consequent ill effects

Critical Care: CV Dressings – particularly I.J. site – getting a dressing to stick!

General Ward: Despite some success, integration with other national initiatives can be difficult

Medicines Management: XXX

Leadership: Creative ways to establish an outreach team ..with no additional resources !

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Successes - GTT

  • Formed a core group of reviewers

  • Detection rate within a ball park figure

  • Provided a platform for other SPSP work streams/Board groups to access

  • Has a high proportion of high risk interventions compared with other hospitals in Scotland

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GTT - What we tried ….

…..with success !

  • Reviewed the entire GTT process

  • Quality assurance that reviewers where carrying out process correctly. Reviewers trained and re-trained

  • Now randomised case note sample into 2 sections/month

  • Medical reviewers will attend at the end of session to determine category of harm caused to patient

  • IHI extranet reporting now based on LOS for case notes reviewed not LOS for entire hospital population

  • Outcome of review session, number of triggers identified within the 20 sets of case notes and overall outcome of harm will be detailed on a “run chart” which will be circulated to all directorate clinical governance committees for their information and feedback

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Challenges - GTT

  • Initially very low rate of harm -Results were showing very little adverse events occurring within GJNH

  • Person dependant

  • Committed but lone input from medicine

  • Small number of reviewers from cardiothoracic/cardiology

  • Data dead end

  • Review information captured on extranet with regarding to Global trigger tool and outcomes measured.

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Moving GTT forward - Opportunities

  • Strong core group

  • Established a reliable, robust process

  • Executive sponsor

  • Now producing two data points per month

  • Beginning to assign level of harm at initial review

  • Our consultant reviewer able to attend review

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Moving GTT Forward -Barriers

  • Medical buy-in

  • Recruitment of reviewers

    • Seasoned clinicians

    • Non-clinical function

    • Requires dedicated time out from clinical duties

  • Function creep

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Summary - GTT

  • GTT implemented and providing insightful data

  • Steady progress, need to work on bedding in process

  • Realised and corrected erroneous results

  • Good multidisciplinary input, need to expand to medical/CTS/cardiology

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And Lastly

How are you integrating your SPSP work with other national initiatives and programmes?

CQI’s (Mews & PVC) Safety Cross; HEAT Targets (SAB/CDI rates ;Productive Operating Theatre

We have also included part of NHS QIS food fluid and nutrition standards onto daily ward handover safety briefing sheet. Inclusion of MUST screening result and does patient require assistance with eating is documented at each handover.

Tell us about any barriers/challenges you have overcome in relation to integrating your SPSP work.

People understanding different formats of information from other initiatives – e.g. SPC charts and Pareto charts

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Success….integration with CQIs/ SCN review

  • Same data collection through excel in use to help improve compliance

  • Helps teams with using similar methods for collecting information….5 case notes per week.

  • SPSP data PVC and MEWS held with CQIs facilitating integration of national initiatives