Leading Evidence-Based Innovation at Your Facility, Part 3: The Team's the Thing
By Kelly Daley, PT, MBA
In earlier posts, I touched on some ideas around how to achieve leadership buy-in for a systematic, evidence-based change in your facility's practice, and how to prepare for and measure effectiveness. Now comes the third step (and the step many consider the most fun): bringing a core team together.
Why can this be so much fun? Because this is where the magic happens. And it really does take a team. Although you may be at the helm of this new program, you'll want to engage several others who offer needed skills as invested team members. In other words, don't make the mistake of seeing this as all yours just because you are leading it.
If you're finding yourself stretched thin, you may want to identify an operational leader. Get help from someone who sees and understands the big picture, and can assist in overcoming barriers, garnering resources, and creating sustainability.
And if you really want to power up your team, consider adding a statistical star. It's very helpful to engage someone who can add statistical and analytics power to your program. This may seem intimidating if you are not in a facility where this type of support already exists (and believe me it doesn't readily exist for 99% of us), but there are ways you can make it happen.
First, remember: you have critical clinical knowledge of the most appropriate outcome measure and its related levels of MCID (minimal clinically important difference). I talked about that in my last post.
Just because your facility doesn't have an identified staff member focused solely on statistics doesn't mean nobody has those skills, so look around internally first. Alternatively, try your DPT university partners—if you provide student internships, then this type of support may be a reasonable trade off.
And here's another avenue: Think about reaching out to known physical therapy researchers who may be willing to be involved in some way. This isn't as impossible as it might sound. You can contact APTA's Professional Affairs Unit at firstname.lastname@example.org for help on identifying the availability of potential researchers. You never know who may be interested in what you're doing.
It is powerful to connect with someone who buys into your evidence-based initiative and can contribute statistical knowledge for the design and production of analytic reports. These reports will speak to the baseline (pre-pilot), initial evaluation, and post-treatment improvements in value. And a statistical specialist can help you think about how you want to slice your data to best suit your facility. Do you need to see these measures as they relate to clusters of ICD-10s? By stratification of patient demographics? By individual therapists? And so on. Having a statistics-minded team member on hand can help you not only get the data, but also think about which data are the most important, and how they should be teased out and presented.
Regardless of whether you're fortunate enough to include both a statistics person and an operational person on your team, the most important thing is to create a team of some kind, and honor it. A strong, engaged core team means local buy-in. You're no longer trying to get everyone to follow "your" idea, because a team approach invites everyone to take ownership in the idea. And that's a good thing. With coworkers on board, you can concentrate on maintaining appropriate momentum, and ensuring no single team member is unduly burdened.
One final tip: never be afraid to ask for advice. You may be championing a truly wonderful idea that could change the lives of your patients, but that fact alone won't make your vision a reality. You need the support and input of others, from assistants who know the on-the-ground realities, to the administration insider who knows the ins and outs of your facility's leadership dynamics, to fellow therapists who may have attempted to introduce innovation at your facility or elsewhere. Ask for their input—and then listen.
Implementing evidence-based innovation can be complicated, confusing, and frustrating. But you can do it. And the payoff—seeing how the change actually makes your facility a better place for your patients, and watching as patients reach better outcomes—is more than worth the effort.
Go for it.
Kelly Daley is clinical informatics program coordinator for Johns Hopkins Hospital, in Baltimore, Maryland.
Leading Evidence-Based Innovation at Your Facility, Part 2: Knowing What Success Looks Like
By Kelly Daley, PT, MBA
Welcome to part 2 in a 3-part collection of tips on how to introduce evidence-based systematic change in your facility. In part 1, I discussed getting buy-in from leadership in order to launch the change. Now let's discuss what happens after you get that support.
The next step? Considering the best measures of success.
You really believe in this change, and you've convinced leadership of its value, so now you need to figure out how you're going to know if the change is really working for your facility. This can get tricky, but stay focused and summon up all your analytical abilities, and you'll be fine.
Of course you'll want to demonstrate that the initiative is actually helping patients to improve by, at the very least, showing incremental improvement over baseline, through a difference in scores between evaluation and end of the episode of care. But you also will need to make the value case (the "amount of improvement, per dollar spent, in outcomes your patients care about" that I covered in the first post in this series). And even more to the point, you'll need to make the value case for the initiative compared with the ways your facility operated before the change.
For instance, for a low back pain initiative you may choose to use the Oswestry score and a count of visits per episode to verify improvement over time, and then multiply the approximate per-visit cost by the average number of visits per episode. You will have not only an understanding of how much improvement patients experienced, but just how much it cost to achieve that level of improvement. After that, you can compare these with similar data from the previous approach, and if all goes as expected, you'll be able to demonstrate value.
If these data are collected and reported by your electronic health record (EHR) or other software, then that's great, but there are other ways to get that information. These other ways could include paper collection (simple, cheap, and low-tech, but takes a lot of manual entering of information to get at value), tablet entry to a database outside of the EMR (such as in a waiting room), or data collection from wrist fitness bands or other devices. And there's always the possibility that you might partner with payers, such as Medicare or private payers, that offer their own analytics around your care patterns for a given diagnosis.
But having a solid source of data isn't enough by itself. It's how you approach it and what you do with it that matters. So ...
Be deliberate. Consider taking your measures of baseline first, before starting a pilot. Then, with leadership's approval, try your pilot with a few patients (and therapists if there is more than 1) for a fixed amount of time.
Evaluate. Gather data from the measures used in your pilot, then carefully consider what you've learned. What incremental improvement have you seen? Have you seen indicators of enough incremental improvement to continue to build this initiative? Remember, it's possible that the pilot didn't do what you had hoped—that's important information too.
Refine. Provided that your pilot has produced outcomes that show promise, combine your pilot information with scholarly evidence (such as clinical practice guidelines) to finalize your proposed initiative. A 2008 article in BMJ titled "Translating evidence into practice: a model for large scale knowledge translation" can give you more insight on the process.
Keep the loop going. Initial buy-in is important, but you also want to ensure long-term engagement from both your leadership sponsor and from the team actively involved in implementing the change. Keep up the monitoring and bring back findings on a regular basis, especially as the formal program takes shape.
(A quick tip: if you want to get a better idea as to whether your approach is on target, a good resource is the "Plan-Do-Study-Act" template offered by CMS—it provides clear, easy-to-follow guidance. Just remember that you're looking toward making systematic, clinic-wide change here—maybe bigger than that—and not just looking at what your own patients are doing.)
It's easy to get excited about implementing a change you believe will make a difference in the lives of your patients, but don't let that excitement turn into impatience. The transition from plan formulation, to pilot testing, to refining the actual program requires a careful approach—but that only increases the chance that the end result will be what got you so excited in the first place.
Coming up in the third and final installment in this series: a few tips on assembling a great team to make the change happen.
Kelly Daley is clinical informatics program coordinator for Johns Hopkins Hospital, in Baltimore, Maryland.
Leading Evidence-Based Innovation at Your Facility, Part 1: Selling Your Idea
By Kelly Daley, PT, MBA
So ... you're treating a patient and while researching the literature to inform your decisions, you've found a clinical practice guideline or other evidence. The evidence looks very promising, and you see the possibilities for positive results.
So, now what?
Well, now you get to lead an innovative systematic change in patient care! By implementing a systematic program at your facility, you affect more than the patient in front of you, you touch all of the targeted patient population coming to you. This is sometimes called “quality improvement” or "translation of evidence."
But, frankly, for some us, those terms sound vague or tedious. Instead, let's just call it impact.
The whole idea of making a big systematic change—making an impact—can seem daunting. And sometimes, it is. But it's also doable. Here are the basic steps to take.
Pitch your proposal.
Leadership needs buy in to your idea, since it will require your facility's support and participation. What needs to be included in the pitch to your leaders? Consider the concept of value—basically the amount of improvement, per dollar spent, in outcomes your patients care about.
If you're the mathematical type, the formula would be value = quality outcome/cost. (And if you want a more detailed look at this concept, check out this article from the New England Journal of Medicine). If you can convince your leadership that your proposal is a way to significantly improve outcomes and reduce cost, chances are you have a winner!
Strengthen that pitch by looking for "fit."
Your evidence might be great, with a great potential for value, but does that value proposition apply to your particular facility? That's a question leadership will asking, so your best bet is to provide them with the answers. To increase the chances of your proposal getting the green light, be sure you can answer "yes" to these questions:
- Does your targeted evidence or guideline speak to a large percentage of your facility's patient population?
- Is the care outlined currently feasible for your setting and staffing?
- Are there low costs or losses involved in setting up a formal pilot?
Be sure to include a review of those issues in your pitch.
Once your leadership provides input and support, see if one of those leaders is willing to be your formal sponsor and champion. It's worth remembering that a leadership mentor and sponsor can reap some benefit by becoming a champion of an initiative that keeps care at your facility high-value.
Stay tuned for Part 2: How to Measure Your Success.
Kelly Daley is clinical informatics program coordinator for Johns Hopkins Hospital, in Baltimore, Maryland.
Dazed and Confused: When Guidelines Conflict
By Philip Van der Wees, PT, PhD
In our ongoing efforts to apply the best evidence to physical therapist practice, we are encouraged to turn to clinical practice guidelines (CPGs) to help us connect with what works.
That is sound advice. CPGs are statements that include recommendations intended to optimize patient care, informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. We want to help our patients and clients, and CPGs provide us with much-needed clarity.
Except when they don't. Read enough CPGs, and you are sure to find conflicting information—not so often in terms of the basic recommendations, but in other important areas that could have an impact on your practice.
For example, an international comparison of CPGs for physical therapist management of patients with hip and knee osteoarthritis (OA) showed some strong similarities, mostly around the recommendation of exercise therapy as a core treatment. But 1 guideline also included transcutaneous electrical nerve stimulation (TENS) for knee OA as a core recommendation, while another classified TENS as an adjunct.
So which is it? And what is the PT supposed to do when guidelines conflict?
The fact is, not all CPGs are created equal. When comparing CPGs on an international scale, it is sometimes true that local health care systems in the country or differences between countries of the CPG's origin may result in different recommendations—a type of variation that showed up in a 2010 study of LBP CPGs from 13 countries as well as 2 international research projects.
But perhaps even more important is the overall quality of any individual CPG document—how it was made, who was involved in making it, and the target it was aiming for. Deficiencies in any of these areas can lead to a CPG that may produce a guideline in conflict with other recommendations. Remember, just because it is called a CPG doesn't necessarily mean that it is providing you with on-target recommendations.
Fortunately, there is a way to differentiate the higher-quality CPGs from the lower-quality ones. It's called AGREE, an instrument comprising a 23-item checklist that assesses the quality of guidelines in 6 domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. A high score on AGREE is a good indicator that the CPG you're reviewing will be accurate and useful.
While it is true that individual clinicians can use the AGREE assessment, the instrument is a thorough one, and may be too time-consuming for use on a day-to-day basis. Instead, try to find out if the CPG authors themselves used AGREE or some other assessment that grounds their work in best practices for CPG development.
This is what makes 2 APTA resources—the CPGs developed by APTA's sections, and the PTJ publication process—worth noting. APTA has developed a guideline methodology process derived from international standards including the AGREE instrument, and applies this methodology to the CPGs developed through its cooperative program with sections. At PTJ, publication of a CPG only happens when that CPG survives a review process to ensure that the guidelines to be published are trustworthy. The end result is that by the time you read a CPG developed by an APTA section and published in PTJ, you can feel confident that you're reading the best the evidence has to offer.
Will guidelines continue to conflict? As long as there are different health care systems, levels of evidence, and perspectives, there will always be differences in at least some recommendations. But if you know how and where to look for the underlying quality of the CPG, you'll be better able to discern what guideline is most likely to help your patients—and that's really what it's all about.
Philip Van der Wees is a researcher for the Scientific Center for Quality of Healthcare in Nijmegen, the Netherlands. He is a member of the PTJ editorial board.
It's Not Just Consumers Who Must Think Differently About Pain
By Steven Z. George, PT, PhD
The United States is in the midst of a costly and deadly opioid epidemic. There are no easy answers to this problem, but physical therapists could be a big part of the solution. Physical therapy's potential for effective pain management has already been recognized by a Centers for Disease Control and Prevention (CDC) initiative indicating that physical therapy should be a front line option for patients with chronic pain conditions. In response, APTA initiated the #ChoosePT campaign to let patients and providers know that physical therapists are a viable early option for pain management.
These are exciting developments, and they bring new opportunities and challenges to our profession. The opportunity is clear: a move away from widespread opioid use could allow more patients with pain to benefit from physical therapy, which offers pain relief that is effective and does not carry the risks associated with opioid use.
The challenge is that if our profession is to become more adept at pain management, we will need to think and act differently about pain. In particular, physical therapists must be willing to change theories and clinical practices that have persisted despite their lack of evidence as being part of an effective pain management strategy.
When I delivered the Maley Lecture at the 2016 NEXT Conference & Exposition, I warned against “silver bullet” treatments – sometimes involving special training, techniques, or equipment – that focus on complete relief of chronic pain. Not only do these approaches risk giving patients unrealistic expectations, they also fail to deliver when tested rigorously in clinical settings, and we end up offering nothing new or improved to our patients.
Physical therapists are uniquely situated in most health care systems to exert considerable leverage for improving acute and chronic pain management. However, to have the largest impact there must be a revolutionary change in our education and practice. Physical therapists must also consider that our biomechanical tendencies are not always well aligned with progressive pain management.
Most immediately, physical therapists must acknowledge that pain is a complex, individual experience, and pain can be affected by many factors in a person's life. In my lecture, I explored the pain experience of someone getting a tattoo to illustrate the profound influence of context on pain ratings.
We know that physical therapy is a safer choice than long-term opioid therapy. But for physical therapist treatment to be solidified as an effective first choice for pain management, we need to ensure that clinical behaviors align with a nuanced understanding of the pain experience.
We need a pain management revolution.
Steven Z. George, PT, PhD, is director of clinical research, Department of Orthopaedics, and director of musculoskeletal research, Duke University Clinical Research Institute. For more of George's perspectives on pain management, watch the video from NEXT 2016's Rothstein Roundtable, "Opioids Versus Physical Therapy: Should Physical Therapy Be the First Choice for Pain Management?"
Cupping: Why We're All Seeing Spots
By Daniel Cobian, PT, DPT, PhD, and Bryan Heiderscheit, PT, PhD
At the 2016 Summer Olympics, Michael Phelps added to the collection of medals that make him "the most decorated Olympian of all time." But the medallions hanging around his neck weren't the only "decorations" that generated attention. The media and public also became fascinated by the tennis ball-sized red circles on his upper back and shoulders.
These welts are the result of cupping, a technique dating back to ancient Greece (making it an appropriate topic during the Olympics) that is common practice in traditional Chinese medicine.1 Dry cupping involves the use of negative pressure to create a suctioning effect without any skin perforation.2 Wet cupping also uses skin suctioning, but with added superficial skin incisions to induce bleeding.3 Cups typically are left on the skin for 5-20 minutes, creating a circular-shaped ecchymosis, which may last for days or weeks. Increasing the time and/or pressure exacerbates the ecchymosis.2
Thanks to Phelps, an ancient technique seemed new again. And, in a cycle that's all too familiar, viewers became intrigued by some "sanctioned," never-before-seen performance enhancer that gets worldwide exposure on the Olympic stage. In 2000, it was Australian sprinter Cathy Freeman's hooded bodysuit. In 2008, it was multicolored kinesiology tape, the Rorschach-like patterns adorning the bodies of volleyball, basketball, and track athletes. Now in 2016, it's the dark circles evident of recent cupping treatments.
Such things naturally draw our attention. And since the top athletes in the world are using these treatments, credibility is inherent or implied, right?
Not always so.
Injury preventing and performance enhancing approaches that rapidly gain widespread popularity will always outpace scientific research. It takes years to systematically investigate the physiological effects of various stimuli with strong scientific methodology, data collection, and analysis, and determine if these interventions are appropriate, how they should be dosed, and who is most likely to respond.
Despite the long history of cupping therapy, there is a noted lack of published evidence supporting it as a treatment for musculoskeletal conditions or defining the mechanisms by which it may have therapeutic value. The suction created by the cup produces a tensile stress on the skin and underlying tissue, along with compressive forces underneath the rim of the cup. These tensile stresses are thought to cause dilation and rupture of the superficial capillaries, creating the reddish-colored circles.2 This may reduce discomfort in the target tissues by stimulating inhibitory neural pathways.4 In this way, cupping may create a "counter irritation" effect that temporarily increases pressure pain thresholds.5,6 Additionally, altered local metabolic activity may contribute to this effect.7 However, these potential mechanisms of action are speculative and have not been thoroughly investigated.
Recent research published in journals of complementary and alternative medicine report that cupping may be beneficial for low back and neck pain,6,8-10 carpal tunnel syndrome,11 and knee osteoarthritis.12 At face value, these results appear quite promising, but they should be appropriately tempered due to the studies' methodologies.13 In each of these investigations, the comparison group received either no treatment or minimal intervention such as the single application of a heating pad.11 Without a true control group that mimics the potential psychological stimulus of a unique and impressive intervention such as cupping, we cannot differentiate true physiological alterations from placebo effect.14
When hundredths of a second are the difference between gold and silver (Phelps won the 200m butterfly by 0.04 second), athletes are looking for any potential real or perceived advantage and often explore alternative approaches. However, this is not done in lieu of the proven standards. Indeed, Phelps and his teammates are privy to round-the-clock medical attention from a team of sports medicine experts, including physical therapists. Olympic athletes regularly receive care that is well supported by strong scientific and clinical evidence. Evidence-based physical therapist treatment for musculoskeletal shoulder dysfunction involves therapeutic exercise,15,16 manual therapy,17 and movement and postural education.18
It's easy to understand why the media and public became fixated on Phelps' use of cupping—the welts were impossible to ignore. But while cupping is an adjunctive treatment that may, through currently unclear physiological or psychological means, have a short-term effect, we must be cautious that the general population doesn't see cupping as a silver-bullet treatment for musculoskeletal conditions.
Olympic athletes might include cupping as part of their extensive physical and mental maintenance to train and compete at maximum capacity, but an underlying theme of the Choosing Wisely campaign is the benefit of active therapy over passive treatments: www.choosingwisely.org/societies/american-physical-therapy-association/. As physical therapists, we want to maintain our position as evidence-based experts in the restoration, maintenance, and promotion of optimal physical function. To do so we must continue to uphold the value of well-established and rigorously investigated interventions in the face of the latest fascination in sports medicine.
Daniel Cobian, PT, DPT, PhD, and Bryan Heiderscheit, PT, PhD are members of the University of Wisconsin-Madison Department of Orthopedics and Rehabilitation.
- Turk JL, Allen E. Bleeding and cupping. Ann R Coll Surg Engl. 1983;65:128-131.
- Rozenfeld E, Kalichman L. New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. J Bodyw Mov Ther. 2016;20:173-178.
- Arslan M, Gokgoz N, Dane S. The effect of traditional wet cupping on shoulder pain and neck pain: A pilot study. Complement Ther Clin Pract. 2016;23:30-33.
- Musial F, Michalsen A, Dobos G. Functional chronic pain syndromes and naturopathic treatments: neurobiological foundations. Forsch Komplementmed. 2008;15:97-103.
- Lauche R, Cramer H, Hohmann C, et al. The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study. Evid Based Complement Alternat Med. 2012;2012:429718.
- Markowski A, Sanford S, Pikowski J, Fauvell D, Cimino D, Caplan S. A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. J Altern Complement Med. 2014;20:113-117.
- Emerich M, Braeunig M, Clement HW, Ludtke R, Huber R. Mode of action of cupping--local metabolism and pain thresholds in neck pain patients and healthy subjects. Complement Ther Med. 2014;22:148-158.
- AlBedah A, Khalil M, Elolemy A, et al. The Use of Wet Cupping for Persistent Nonspecific Low Back Pain: Randomized Controlled Clinical Trial. J Altern Complement Med. 2015;21:504-508.
- Chi LM, Lin LM, Chen CL, Wang SF, Lai HL, Peng TC. The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2016;2016:7358918.
- Lauche R, Langhorst J, Dobos GJ, Cramer H. Clinically meaningful differences in pain, disability and quality of life for chronic nonspecific neck pain - a reanalysis of 4 randomized controlled trials of cupping therapy. Complement Ther Med. 2013;21:342-347.
- Michalsen A, Bock S, Ludtke R, et al. Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized controlled trial. J Pain. 2009;10:601-608.
- Teut M, Kaiser S, Ortiz M, et al. Pulsatile dry cupping in patients with osteoarthritis of the knee - a randomized controlled exploratory trial. BMC Complement Altern Med. 2012;12:184.
- Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for treating pain: a systematic review. Evid Based Complement Alternat Med. 2011;2011:467014.
- Ernst E. Testing traditional cupping therapy. J Pain. 2009;10:555.
- Haik MN, Alburquerque-Sendin F, Moreira RF, Pires ED, Camargo PR. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016.
- Marinko LN, Chacko JM, Dalton D, Chacko CC. The effectiveness of therapeutic exercise for painful shoulder conditions: a meta-analysis. J Shoulder Elbow Surg. 2011;20:1351-1359.
- Camarinos J, Marinko L. Effectiveness of manual physical therapy for painful shoulder conditions: a systematic review. J Man Manip Ther. 2009;17:206-215.
- Lewis J, McCreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther. 2015;45:923-937.
Confessions of a Tech-Challenged PT: Sweet (Evidence) Dreams Are Made of These
By Stephanie Miller, PT
Want to know how tech-savvy I am? I'll give you a couple of clues. First, let's just say it's been "a few" years since I graduated from PT school. Second, I don't have TV or Internet at my house. So when it comes to technology, I know that I probably have a lot of … catching up to do.
I never wanted my non-techiness to stop me from progressing in my field, though. I didn’t want it to be a barrier. But to be honest, it was.
I’d see a patient with a diagnosis or procedure I hadn’t encountered for a while, and I would want to find the latest information and research on the topic. I’d type a few words into a search engine, cross my fingers, and hope I got something. Either I got no relevant results, or when I finally found a gem of an article it would tease me with the abstract, then take me to a subscription page. (And the worst was when that new page wouldn’t allow me to get back to my original search, no matter how many times I clicked the Back arrow.) To find a full-text article that I didn’t have to sell my soul to get was nearly unheard of. Then, if by some slim chance I did find one, I often wanted to find another article that was referenced within it, only to start the self-defeating process all over again. I found it completely frustrating, and after hours of searching and bouncing around from site to site, I would still come up nearly empty-handed.
I kept wondering, why couldn’t someone come up with an easy-to-use, one-stop shop? Well, they did. It's called PTNow, and, best of all, it's free to APTA members. It has changed my world as a health care professional and I hope that it does the same for you!
I’ll dive deeper into all that this site offers in future blogs. But just to give you a taste, you have access to: various search engines, clinical practice guidelines, free full-text articles from tons of publications (yes, I said free), access to and permission (yes, you read correctly, permission!) to use various tests and tools for patient examination, and clinical summaries. There's a new point-of-care resource called the Rehabilitation Reference Center that delivers need-to-know-now information. And there’s even MyPTNow, a space for you to save searches and clinical collections for future access. But I don’t want to get ahead of myself, and, honestly, I’m still learning all of the new features.
You know as well as I do that our treatments and documentation are being subjected to more and more scrutiny. I can’t see that lessening in the future. To continue to justify that we give the best care (as we know we do), we need the research, tests, and quality measures for support. PTNow is a great, easy-to-use place to find them.
I’m looking forward to bringing you more tips and tricks in the future, as well as learning and growing with you along the way. In the meantime, I challenge you to try out the site until you hear from me again. If you’re intimidated by it, don’t be: there’s a great tutorial video that will walk you through some basics, and there’s even access to a librarian who can assist you with questions along the way.
Take it from me, one of the most un-techy people you'll meet: this is something worth plugging into.
Stephanie Miller is a staff development specialist with Celtic Healthcare.
Explore other posts from the "Narrow the Gap" series.