BMI Healthcare
Serious about health. Passionate about care.
BMI Blackheath Hospital Quality Accounts
April 2014 to March 2015
BMI Blackheath Hospital Quality Accounts May 2015
1
BMI Healthcare
Serious about health. Passionate about care.
Chief Executive’s Statement
I am pleased to welcome you to our Quality Accounts 2015.
Now in their sixth year, Quality Accounts continue to provide a truly
objective metric for us, and others, to gauge the quality of our 59
hospitals and the services they provide against a broad range of
criteria.
The past year has seen another step change in the way healthcare
providers are externally challenged on the quality they provide.
Following a spate of high profile controversies around patient safety,
the Care Quality Commission, the UK’s health regulator, has
introduced a new inspection regime designed to raise standards.
No healthcare provider can afford to be complacent and whilst I
believe BMI’s hospitals provide safe and effective care, we should
always be striving for improvement.
To this end we recently introduced a new Quality Strategy, which
articulates how we will provide the best possible care and strive for continual improvement, and live up to
our brand promise to be “serious about health, passionate about care”. Its four core themes – safety,
clinical effectiveness, patient experience and quality assurance – provide our staff with the platform to
consistently deliver the care patients, their insurers, and commissioners expect and deserve.
BMI hospitals have been enthusiastic participants in the pilot programme of the new CQC inspection
regime for private providers, and to ensure our facilities are prepared we have developed a selfassessment tool to enable hospitals to compare their perceptions of themselves with those of the external
inspectors. The rigorous inspection process itself also underpins the sharing of best practice between
hospitals which further drives improvement and consistency.
BMI Healthcare strives to provide the best care but the ultimate arbiters of whether we succeed are our
patients. We are committed to monitoring every aspect of the care we provide, and the results of the
detailed questionnaires we ask patients to complete inform improvement. We aim to provide a consistent,
high quality patient experience and an environment that empowers our consultants to excel. Providing a
dependably high quality of care requires constant focus on improvement; the most recent independent
research conducted for BMI shows that over 98% of our patients rate their care as excellent or very good.
The information available here has been reviewed by the Clinical Governance Board and I declare that as
far as I am aware the information contained in these reports is accurate. Finally I would like to thank all
the staff whose application, professionalism and ceaseless commitment to improvement is recognized
here and in the positive experiences of the patients we care for. Since I joined BMI late last year, I have
witnessed this firsthand on my many visits to our hospitals and I am committed to ensuring we build on
that success.
Jill Watts, Group Chief Executive
BMI Blackheath Hospital Quality Accounts May 2015
2
BMI Healthcare
Serious about health. Passionate about care.
Blackheath Hospital Information
The Blackheath Hospital is a 68 bedded facility located in Blackheath Village, well serviced by
public transport links.
Patient rooms are located over 2 wards. Most of the rooms are single with en-suite facilities with
the exception of two double suites. Blackheath offers a broad range of surgical specialties
including orthopaedic, neurosurgical (spinal), gynaecology, urology, ENT, colorectal and general
surgery. There is also a dedicated endoscopy unit.
A theatre refurbishment programme was completed in May 2014; this has given us 3 state of
the art theatres [2 with laminar flow] and a 6 bedded recovery area.
Approximately 25% of our patients are NHS patients through the Choose and Book scheme.
Our management team is in close communication with the local commissioning boards, and
participates in CQUINS and other quality indicators.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Blackheath Hospital is registered as a location for the
following regulated services:Treatment of disease, disorder and injury
Surgical procedures
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
Diagnostic and screening
Family Planning
We ceased offering the service of Termination of Pregnancy in January 2015 following a review
of the service, which was under utilised. [Only 3 terminations had been performed throughout a
1 year period] Any patients requiring this service are given contact details for the Marie Stopes
clinics.
The CQC carried out an announced inspection of the hospital between 10th and 12th February
2015. This inspection formed part of the second wave of pilot inspections of independent care
providers. The final report was published on the CQC website on 22 May 2015, as follows
CQC INSPECTION AREA AND RATINGS
SAFE
REQUIRES IMPROVEMENT
EFFECTIVE
REQUIRES IMPROVEMENT
CARING
GOOD
RESPONSIVE
REQUIRES IMPROVEMENT
WELL-LED
REQUIRES IMPROVEMENT
CQC RATINGS AND INSPECTIONS OF SPECIFIC SERVICES
URGENT & EMERGENCY SERVICES
GOOD
MEDICAL CARE [INCLUDING OLDER
REQUIRES IMPROVEMENT
PEOPLES’ CARE]
SURGERY
REQUIRES IMPROVEMENT
SERVICES FOR CHILDREN AND YOUNG
REQUIRES IMPROVEMENT
PEOPLE
OUTPATIENTS
GOOD
An extensive action plan has been developed, and will be shared with all Blackheath staff
members. The main issues were around environmental [decontamination] issues in the
Endoscopy area, and environmental and staffing issues in the High Dependency unit.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
A summary of the actions we have and will be taking has been produced and will be displayed
alongside the published ratings for patient and public information in the reception areas.
Some changes were made immediately:
•
•
•
•
•
•
The Hospital took the decision to suspend on-site endoscopy decontamination services
on 29th May and a new endoscopy washer and RO unit has been installed and some
other remedial works are due to complete on 17th July 2015
The High Dependency unit has been temporarily renamed as an Enhanced Care Unit
and admission is based on set criteria [booked and screened elective post-operative
cases] and no emergency admissions are accepted.
The Quality and Risk Manager is attending Dementia awareness training with the
Alzheimer’s Society and will then disseminate to hospital staff and additional Mental
Capacity Training has been arranged.
Removal of carpets in reception areas of the hospital and outpatient buildings, replacing
them with appropriate hardwood flooring
Setting up an additional series of ANTT [Aseptic non touch technique] training for clinical
staff
Additionally extra mandatory training sessions have been arranged, resulting in the
hospital reaching 89% compliance with mandatory training requirements by 10 Jun.
Regional Clinical Quality Assurance Groups monitor and analyse trends and ensure that the
quality improvements are operationalised.
At corporate level the Clinical Governance Board has an overview and provides the strategic
leadership for corporate learning and quality improvement.
There has been ongoing focus on robust reporting of all incidents, near misses and outcomes.
Data quality has been improved by ongoing training and database improvements. New reporting
modules have increased the speed at which reports are available and the range of fields for
analysis. This ensures the availability of information for effective clinical governance with
implementation of appropriate actions to prevent recurrences in order to improve quality and
safety for patients, visitors and staff.
At present we provide full, standardised information to the NHS, including coding of procedures,
diagnoses and co-morbidities and PROMs for NHS patients.There are additional external
reporting requirements for CQC, Public Health England (Previously HPA) CCGs and Insurers
BMI is a founding member of the Private Healthcare Information Network (PHIN) UK – where
we produce a data set of all patient episodes approaching HES-equivalency and submit this to
PHIN for publication. The data is made available to common standards for inclusion in
comparative metrics, and is published on the PHIN website http://www.phin.org.uk. This website
gives patients information to help them choose or find out more about an independent hospital
including the ability to search by location and procedure.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
1. SAFETY:
1.1 Infection prevention and control
The focus on infection prevention and control continues
under the leadership of the Group Director of Infection
Prevention and Control and Group Head of Infection
Prevention and Control, in liaison with the Infection
Prevention and Control Lead at The Blackheath Hospital.
We have had: •
0 reported cases of MRSA bacteraemia per 100,000
bed days in the last year (NHS 1.17cases/100,000 bed
days).
•
0 reported MSSA bacteraemia cases /100,000 bed days
•
0 reported E.coli bacteraemia cases/ 100,000 bed days
•
0 cases of hospital apportioned Clostridium difficile in the last 12 months.
•
We are in the process of collecting SSI data for submission to Public Health England for
orthopaedic surgical procedures. Our rates of infection are 0 % for both hips and knees.
Infection prevention and control audits are undertaken in all areas on a monthly basis. There
is a renewed focus on hand hygiene and ANTT training and audits which are then collated
at reported at quarterly Infection Prevention and Control Committee meetings.
Additionally the Infection Prevention and Control nurse has delivered Sharps Awareness
workshops. Participation in infection control audits have improved during the latter half of the
year.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
1.2 Patient Led Assessment of the Care Environment (PLACE)
We believe a patient should be cared for with compassion and dignity in a clean, safe
environment. Where standards fall short, they should be able to draw it to the attention of
managers and hold the service to account. PLACE assessments will provide motivation for
improvement by providing a clear message, directly from patients, about how the environment
or services might be enhanced.
In 2013 we introduced PLACE, which is the new system for assessing the quality of the patient
environment, replacing the old Patient Environment Action Team (PEAT) inspections.
The assessments involve patients and staff who assess the hospital and how the environment
supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It
focuses entirely on the care environment and does not cover clinical care provision or how well
staff are doing their job.
The PLACE audit for Blackheath Hospital was carried out in May 2015 and involved two patient
assessors and two staff assessors split into 2 teams, with results as follows:-
Organization
National level
score
Blackheath
Hospital
Cleanliness
Food
Privacy,
Condition,
Dignity &
Appearance &
Wellbeing
Maintenance
97.25%
88.79%
87.73%
91.97%
98.69%
95.92%
82.69%
92.31%
BMI Blackheath Hospital Quality Accounts May 2015
Dementia
82.77%
7
BMI Healthcare
Serious about health. Passionate about care.
1.3 Venous Thrombo-embolism (VTE):
BMI Healthcare holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including BMI Blackheath Hospital. BMI Healthcare was
awarded the Best VTE Education Initiative Award category by Lifeblood in February 2013
and were the Runners up in the Best VTE Patient Information category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assessment every patient who is admitted to
our facility and the results of our audit on this has shown a 100% compliance rate.
The Blackheath Hospital reports the incidence of Venous Thromboembolism (VTE) through
the corporate clinical incident system. It is acknowledged that the challenge is receiving
information for patients who may return to their GPs or other hospitals for diagnosis and/or
treatment of VTE post discharge from the Hospital. As such we may not be made aware of
them. We continue to work with our Consultants and referrers in order to ensure that we
have as much data as possible. These figures from 2014-15 show that VTE incident
numbers remain very low. Any incidents are investigated and a root cause analysis carried
out.
Numbers
Rate per 100 Admissions
DVT
0
0.000
PE
1
0.129
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BMI Healthcare
Serious about health. Passionate about care.
2. EFFECTIVENESS:
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) are a means of collecting information on
the effectiveness of care delivered to NHS patients as perceived by the patients
themselves. PROMs are a Department of Health led programme.
For the current reporting period, the tables below demonstrate that the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients
undergoing hip replacement and knee replacement at The Blackheath Hospital.
Unfortunately there were less than 30 patients who went through this pathway during the
reporting period, and so no score has been provided.
Oxford Hip Score average
April 14 – September 14
Q1
Q2
Health gain between reporting
periods
BMI Blackheath Hospital
NA
NA
NA
18.16
40.081
21.922
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
Oxford Knee Score average
April 14 – September 14
Q1
Q2
Health gain between reporting
periods
BMI Blackheath Hospital
NA
NA
NA
19.401
36.103
16.702
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
2.2 Enhanced Recovery Programme (ERP):
The ERP is about improving patient outcomes and speeding up a patient’s recovery after
surgery. ERP focuses on making sure patients are active participants in their own recovery
and always receive evidence based care at the right time. It is often referred to as rapid
recovery, is a new, evidence-based model of care that creates fitter patients who recover
faster from major surgery. It is the modern way for treating patients where day surgery is
not appropriate.
ERP is based on the following principles:1. All Patients are on a pathway of care
a. Following best practice models of evidenced based care
b. Reduced length of stay
2. Patient Preparation
a. Pre Admission assessment undertaken
b. Group Education sessions
c. Optimizing the patient prior to admission – i.e HB optimisation, control comorbidities, medication assessment – stopping medication plan.
d. Commencement of discharge planning
3. Proactive patient management
a. Maintaining good pre-operative hydration
b. Minimising the risk of post-operative nausea and vomiting
c. Maintaining normothermia pre and post operatively
d. Early mobilisation
4. Encouraging patients have an active role in their recovery
a. Participate in the decision making process prior to surgery
b. Education of patient and family
c. Setting own goals daily
d. Participate in their discharge planning
We have seen our average length of stay reduce over the past year through reporting
any delayed discharges on Sentinel to monitor trends, working with consultants to review
their booking process and setting up pre assessment physiotherapy sessions.
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BMI Healthcare
Serious about health. Passionate about care.
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BMI Healthcare
Serious about health. Passionate about care.
2.3 Unplanned Readmissions within 31 days and Unplanned Returns to Theatre:
Unplanned readmissions and unplanned returns to theatre are normally due to a clinical
complication related to the original surgery. Our rates remain low, and there have not been
any trends amongst specialties or consultants during this period.
Unplanned return to theatre (Rate per 100
Theatre Cases)
0.250
0.2284
0.2142
0.200
0.1804
2009
2010
0.150
0.1290
2011
0.100
0.0805
0.0683
0.050
2012
2013
0.0330
2014
2015
2015
2014
2013
2012
2011
2010
2009
0.000
Reasons for readmissions and unplanned returns to theatre are monitored through our monthly
clinical governance committee meetings, and no adverse trends identified. Furthermore these
rates are comparable to or lower than other BMI sites of a similar size
3. PATIENT EXPERIENCE:
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
3.1 Patient satisfaction:
BMI Healthcare is committed to providing the highest levels of quality of care to all of our
patients. We continually monitor how we are performing by asking patients to complete a
patient satisfaction questionnaire. Patient satisfaction surveys are administered by an
independent third party.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
The Blackheath Hospital has set up working patient satisfaction groups to meet regarding
particular issues or trends. A patient satisfaction action plan can be viewed by all on the shared
Everyone Drive. Issues from complaints, incidents and feedback are incorporated into this.
3.2 Complaints:
In addition to providing all patients with an opportunity to complete a satisfaction survey
BMI Blackheath Hospital actively encourages feedback both informally and formally.
Patients are supported through a robust complaints procedure, operated over three stages:
Stage 1:
Hospital resolution
Stage 2:
Stage 3:
Corporate resolution
Patient can ref their complaint to independent adjudication if they are not
satisfied with the outcome at the other 2 stages
There has been a steady rise in complaints reporting over the past few years. Staff are more
aware of the value of reporting, investigating and learning from complaints. Complaints themes
are incorporated into the patient satisfaction action plan, along with the monthly patient
satisfaction report issues.
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BMI Healthcare
Serious about health. Passionate about care.
The majority of complaints are financial, in particular around transparency of fees [particularly
pathology] which we are continually looking at ways to improve through signage and patient
information. Other complaint themes are around dissatisfaction with clinical outcome, or clinical
care received. We aim to respond within 20 working days, and complaints are discussed
weekly at the extended 10@10 meeting, as well as the monthly Heads of Department meeting.
BMI Blackheath Hospital Quality Accounts May 2015
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BMI Healthcare
Serious about health. Passionate about care.
4. CQUINS:
The Blackheath Hospital took part in CQUINs for South East London London, the Friends
and Family test, the Safety Thermometer focusing on falls, and Alcohol Intervention, Follow
up DNA rates and Discharge Summaries to GPs were monitored in FY14-15 , with additional
audits on Smoking Cessation, Nutritional Assessments and WHO checklist carried out for
London.
5. NATIONAL CLINICAL AUDITS:
The Blackheath Hospital was only eligible to participate in National Joint Registry audit and
all joint replacements are submitted to this.
In May 2014 the Blackheath Oncology Unit was awarded the Macmillan Quality Environment
Mark, receiving the highest possible score.
6. RESEARCH:
No research studies are carried out at The Blackheath Hospital
7. PRIORITIES FOR SERVICE IMPROVEMENT:
Refurbishment of the Endoscopy Unit to achieve overall JAG compliance
Development of a Critical Care Unit and therefore increased acuity
Replacement programme of carpets in patient rooms
General refurbishment and redecoration
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BMI Healthcare
Serious about health. Passionate about care.
8. MANDATORY QUALITY INDICATORS:
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for
the Blackheath Hospital for the reporting period.
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0.0158
April 2014-March 2015
0.9987
1.1849
0.58345
This value represents the rate of mortalities at the hospital in the reporting period. This was
below the lowest national score. All mortalities were non-perioperative, with only one
unexpected.
8.2 The Blackheath Hospital patient reported outcome measures scores for
(i) Groin hernia surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
April 14 – Sept 14
0.0786
0.278
-0.112
There were minimum numbers going through the process for groin surgery so the
Blackheath Hospital was unable to be scored on this element.
The Blackheath Hospital intends to take the following actions to improve this score, and
therefore the quality of service by promoting completion of the PROMS with every patient.
(ii) Varicose vein surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
April 14 – Sept 14
-7.395
-1.957
-12.571
No data was provided for varicose veins.
(iii) Hip replacement surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
Apr 14 – Sept 14
21.542
28.6
9.714
(iv) Knee replacement surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
Apr 14 – Sept 14
16.641
24.429
5.833
As with groin surgery above there were minimum numbers going through the process for
hip and knee replacement surgery so the Blackheath Hospital was unable to be scored on
this element. Actions are as with groin surgery.
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BMI Healthcare
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8.3 (i) The percentage of patients aged 0-14 readmitted to the hospital within 28 days of
being discharged:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0%
Apr 14- Mar 15
11.45
14.35
7.96
(ii) The percentage of patients aged 15 or over readmitted to the hospital within 28
days of being discharged:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0.05%
Apr 14- Mar 15
10.01
14.51
5.54
The percentages for BMI Blackheath Hospital are well below the national average. Readmission rates continue to be monitored on a monthly basis to observe for trends.
8.4 The BMI Blackheath’s responsiveness to the personal needs of its patients during the
reporting period:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
81.28
Apr 14- Mar 15
68.7
85
54.4
This figure again exceeds the highest national score. Responsiveness continues to be
monitored on a monthly basis through patient satisfaction data, monitoring of patient
satisfaction action plans at monthly meetings, and daily patient visits enabling immediate
action to rectify any issues raised.
8.5 The percentage of patients who were admitted to BMI Blackheath Hospital and who
were risk assessed for venous thromboembolism (VTE) during the reporting period:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
99.99%
Apr 14- Mar 15
95
100
87
This score is above the national average and is an improvement upon last year’s score of
97%. This is down to a focus on VTE risk assessment through monthly audits.
8.6 The rate per 100,000 bed cases of C difficile infection reported within The BMI
Blackheath Hospital amongst patients aged 2 or over during the reporting period:
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Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0
Apr 14- Mar 15
14.7
37.1
0
Again this meets the lowest national score and will continue to be maintained through strict
adherence to infection prevention and control practices, policies, surveillance and audits,
and working closely with our Consultant Microbiologist.
8.7 The number and rate of patient safety incidents reported within The BMI Blackheath
Hospital during the reporting period:
Number of patient safety incidents reported:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
106
Apr 14- Mar 15
20
139
0
Rate of patient safety incidents reported (per 100 bed days):
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
2.36*
Apr 14- Mar 15
3.589
7.496
0.0245
Number of patient safety incidents that resulted in severe harm or death:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0*
Apr 14- Mar 15
40.2
97
0
Percentage of patient safety that resulted in severe harm or death (per 100
admissions):
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0%*
Apr 14- Mar 15
0.3
2.4
0
8.8 The percentage of staff employed by BMI BlackheathHospital who would recommend
the hospital as a provider of care to their family or friends:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
2014
64.58
96.43
33.73
There are no figures available for staff recommendations.
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9. NON MANDATORY QUALITY INDICATORS:
9.1 The percentage of those who received care as inpatients or discharged from A&E
who would recommend BMI BlackheathHospital as a provider of care to their family
or friends:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
73.75 %
Apr 13- Mar 14
66.23
94.38
35.63
Year 2014-15 has been a busy one for the Blackheath Hospital, with a new Executive
Director and Director of Clinical Services taking up post. It is hoped that 2015/16 will
see the construction of a new Endoscopy Unit and Critical Care Unit.
BMI Blackheath Hospital Quality Accounts May 2015
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