Heroics and Habits: Exploring the Implementation
of Lean Management in Healthcare
National Health Leadership ConferenceHalifax, Nova Scotia
June 4-5, 2012Margaret Seppelt BSN, MBA Provincial Health Services AuthorityCindy Priddy BS, MA, MCS Vancouver Coastal Health Authority
Objectives
•Understand a Lean Management System•Describe the role of a leader in a Lean culture•Explore the journeys of two healthcare authorities in BC•Discuss the implications for Canadian healthcare
•What is a typical day of a manager?
•How much of the day is spent fire fighting versus improving the business?
•How easy is it to train someone to be a successful manager in this environment?
A Day In The Life Of A Manager…So my typical day starts about 0645 and I check in to see if there are any patient safety alerts on line, then move to Patient Unit A and get report on night shift, then upstairs to Patient Unit B to check in with the charge nurse and see if she has everything she needs.
The check in time varies and depending on when my first meeting depends on how much time I can spend in each space. For example my first meeting was a 0645 this morning so I was here at 0615 which did not allow for me to get handover, but did check in with a number of staff before the meeting.
My days are jammed with meetings, they would go until 1700 if I did not refuse to meet after 1600. I usually answer emails while eating my lunch at my desk and then answer a few at home in the evening.
Project work gets jammed in between meetings and I usually end up staying some nights until 1800…..but generally try to leave by 1700….
I think what I struggle with the most is having so many things needing attention and prioritizing and putting off people because I just don’t have time to address their issues at that moment. I think the leadership structure is insufficient for the amount of work that needs to be done. Leadership development for the supervisor group is quite important, but has not been able to really sink my teeth into it because of so many other pressing human resource issues...
Today’s Reality of Healthcare Management
Heroes or Firefighters?
FrontLine Leader
Definition of Lean
Lean is a mindset of continuous improvement
It’s a system that empowers people at all levels to:
• Remove waste• Maximize what is of value to the patient
FOCUS = TOOLS AND “PROJECTS”
LACK OF FOCUS ON LEAN MANAGEMENT TO SUSTAIN
3 YEARS
Results/G
ains
Typical Progress of Lean Adoption
Lean Management•An organization’s culture is a result of its management system. To change culture, you have to change your management system.
•Many lean implementations fail because it is easy to implement the physical trapping of lean methods and tools while failing to address the need for the parallel implementation of lean management.
•Lean transformation requires the adoption of the Lean Management System as the system for managing operations and the foundation for all the improvement work and the strategic plan. (Gary Kaplan, Virginia Mason)
PURPOSE
PEOPLE PROCESS
MANAGEMENT
PURPOSE
PEOPLE
PROCESS
Focus too much on the process and tools -
Andons, Kanban, Cells –lean tools and processes
in place without sustained results
PURPOSE
PEOPLE
PROCESS
Focus too much on people and teamwork –
lots of busy improvement activity
with no significant results
Lack of direction
MANAGEMENT
PEOPLE PROCESS?
Lean Management System
MANAGEMENT
PURPOSE
PEOPLE PROCESS
Management aligned to a defined business purpose to deliver results by maintaining the balance
between people and process.
What is the Role of a Leader in a Lean Culture?
1. Set direction 2. Build the problem solving muscle of the organization
Elements of Daily Management
Source: Creating a Lean Culture (Mann, 2005).
Leader Standard Work
Source: Creating a Lean Culture (Mann, 2005).
“Standard Work is the Key to our success…”
“We will be auditing standard work and hold all of you accountable… “
Sure glad Standard Work does not apply
to ME!
Leader Standard Work
*adapted from Creating a Lean Culture, p. 43.
Senior Leader standard work
Director standard work
Manager standard work
Coordinator standard work
Lean Management System
Standardized Lean Processes
Leaders’ Responses to Standard Work for Leaders
“I already do this.”
“I have standard things I’m checking on everyday, I just don’t write it down.”
“This is so formal. I would rather just have casual conversations with staff to get this information.”
“I don’t have time to do this.”
Leader Standard Work•Leader Standard Work is the specific timing, sequence, content and outcomes of a leader’s daily routine.
•The Leader Standard Work identifies audit points and specifies where and when in the leader must physically go, what they must check and the normal condition with the aid of effective visual controls.
•Each check point involves Assessment, Assignment and Accountability.
Leader Standard Work - ExampleReference: Joan Wellman and Associates
Charge Supervisor Manager Director Team Standard Work Huddle Charge Huddle and Application
Consistency Coordinator Huddle and Huddle Design / Expectations
Monthly DMS Reviews and Appropriate Huddle Application
Team Integration and Coordination
Shift to Shift Integration and Coordination
Group Integration and Coordination
Value Stream Process Integration
Respond to Andon / Line Stop Learn from Andon and Codify Share Andon Learning Develop Learning Capabilities Monitor Standard Work Performance
Monitor Standard Work Performance
Monitor Standard Work Performance
Monitor Standard Work Performance
Perform Local Daily Management
Review Performance and Process Metrics
Review Performance and Results Metrics
Review Performance and Outcome Metrics
Analyze Variation Standard Work Variation Management
Variation Trend Analysis Management
Variation Trend Analysis Review
Daily Continuous Improvement Area Continuous Improvement Support
Department Continuous Improvement Support
Organizational Continuous Improvement Support
Individual Accountability Check
Charge Accountability Check Coordinator Accountability Check
Manager Accountability Check
Utilize Visual Management Utilize and Evaluate Visual Management
Support Design and Implementation of Visual Management
Evaluate Effectiveness of Departmental Visual Management
Revise / Reinforce Standard Work
Evaluate Cross Shift Standard Work Change Impact
Evaluate Cross Functional Standard Work Change Impact
Establish Standard Work Expectations
Utilize Five S Process Assure Workplace Organization review for system inadequacies
Evaluate for trends and assure prevention measures are key
Evaluate for principle consistency between areas
Next Day Planning Weekly / Monthly Planning Monthly / Yearly Planning Yearly / Long Term Planning Immediate Issue Problem Solving
Ensure Permanent Problem Solving
Formalized Problem Solving and Assure Effectiveness
Share Effective Formalized PS Approach and Institutionalize
Standard Work Compliance and Correction
Assure Compliance and Resolve Variances
Evaluation Compliance Variances and Resolution Methods
Establish Compliance Expectations and Consequences
Train Team as Needed and Orient to Standard Work
Instruct Charge as Needed and Orient to Charge Standard Work
Instruct Coordinator as Needed and Orient to Coordinator Standard Work
Educate Manager as Needed and Orient to Manager Standard Work
A
Tiered Accountability - ExampleTiered Accountability – Standard Work Huddles
Activity / Response Routine Mgt Tier Frequency
Review for appropriate huddle application and determine departmental huddle effectiveness. Correct for variations of purpose.
Schedule and attend a huddle within each area of responsibility
Director Weekly
Review for process compliance and local huddle effectiveness. Provide coach based on appraisal. Reconcile huddle to huddle variation and adjust organizational structure.
Schedule and attend a huddle within each area of responsibility
Manager Weekly
Assess for process compliance (assess / assign / account), content, duration and effectiveness. Suggest adjustments for inadequacies or inconsistencies.
Attend a huddle within each area of responsibility
Supervisor Daily
Review DMM and respond to abnormalities or failures (assess/assign/account). Utilize appropriate response system. Pursue Continuous Improvement of Standard Work. Correct inadequacies as found.
Lead daily huddle in area of responsibility
Charge RN Daily
Contribute to DMM review. Complete assignments. Generate ideas for improvement.
Attend assigned huddle.
All Associates Daily
A
Source: Joan Wellman and Associates
Routines - Example
Charge Nurse Routine Activity Time Frequency
1. Attend Standard Work Huddle 8am Daily 2. Review and Affinitize Cause Cards Mid Morning Daily 3. Review Offline Activity Mid Day Monday 4. Lead Data Analysis 10am Wednesday 5. Review open action items for
accountability 2pm Daily
6. Audit DMM for Validity Mid Day Wednesday 7. Lead Standard Work Huddle 4pm Daily
Visual Controls
Source: Creating a Lean Culture (Mann, 2005).
Is Your Workplace Visual?If you walked your workplace, can you quickly and easily see:
•Whether you are on plan, behind or ahead?
•What your key problems/issues are?
•What actions being taken to address issues and by when?
•Who is accountable?
Visual Controls
Continuous Process Monitoring
A Plan for Every Patient in Emergency featuring target times for each process step and highlighting any variance against plan as soon as it occurs
Source: LeanUK.org
Daily Management Gemba Walks1
2
3
Leader Standard Work Cascading Reviews
• The same review is done by all
• All that changes is scope and frequency
VP
Manager
Unit Supervisor
Weekly walk by and one deep dive
Daily walk by and one deep dive
Several deep dives throughout the day
Daily Management Board
Daily Management Board – Example PEOPLE QUALITY
SAFETY
DELIVERY CONTINUOUS IMPROVEMENT
COST
Daily Management Board Industry Examples
Daily Management BoardSeattle Children’s
Performance Walls
BC Mental Health Performance WallStrategic level performance weekly review of the Value Stream
(C&GCR – Charts and Graphs in the Conference Room)
Moving Beyond Social Visits…
Leadership Huddles or Walk-aroundswithout Visual Controls are “social visits” …
Visual Controls without Leadership Huddles become “wall paper”
Daily Accountability
Source: Creating a Lean Culture (Mann, 2005).
Daily Accountability Process
Brief, structured, tiered meetings focused on performance with visual action assignments and follow-up to close gaps between actual results vs. expected performance.– Leader scrutinizes data daily – Determines what steps to take by whom– Assigns resources, sets due dates– Tiered Meetings
– 1st tier – Daily Huddle (supervisors and staff)– 2nd tier – Daily Status Review (Managers and supervisors)– 3rd tier – Weekly Gemba (Executives and Managers)
Daily Huddle - Example
Issues Log - Example
Staff submit issues and Front Line Leader reviews issues daily.
Daily Accountability Board - Example
Discipline Adherence to Standards
Source: Creating a Lean Culture (Mann, 2005).
Daily Management Discipline
Change in Leadership Approach from Heroics to Habits
Source: Adapted from Creating a Lean Culture (Mann, 2005).
Her
oics • Focus on results
• Retrospective computer-generated reports
• Focus on the end outcome
• Meetings to discuss reports
• The fire truck
Hab
its
• Focus on process• Looking at what is
happening today in real time
• Focus on the process from beginning to end
• In the moment diagnoses and remedial action
• Fire prevention!
Paradigm ShiftTypical Thinking:Normal daily management plus improvement
Continuous Improvement Thinking:Normal daily management is process improvement
Source: Toyota Kata (Rother, 2010) p. 39
Provincial Health Services Authority• One of six health authorities in BC established in 2001• Responsible for highly specialized services in the
province:– BC Children’s Hospital - BC Centre for Disease Control– BC Women’s Hospital - BC Transplant Society– BC Cancer Agency - BC Provincial Renal Agency– Mental Health & Addictions - Cardiac Services BC– Perinatal Services BC
• PHSA Divisions– Emergency Health Services Commission– Health Shared Services BC
• 16,000 employees• Serve a population of 4M • Budget of $2.3 billion
PHSA’s Lean Transformation Strategy imPROVE, focusing on patients; empowering staff
Based on our organizational values:P: Patients firstR: Results matterO: Open to possibilities V: Best ValueE: Excellence through knowledge
- it’s about improving processes to ultimately improve patient care/outcomes
imPROVE Roadmap
Year 1 - 22007 - 2011
2011 - 20132013 - 2014
Experiment with Lean Methods and Tools as Improvement Projects
Move from point improvements to Value Streams and Rapid Process Improvement Workshops. Leaders Certified in Lean Methods and Tools.
Daily Management supports sustainment and front line staff engagement in identification and improvement of key issues.
Strategy Deployment to define Key Breakthrough Objectives with clear accountability and reporting from the top to the front line.
Developing Lean Leaders
Learning How to Improve•Learning lean principles•Applying methods, and tools•Mapping Value Streams•Leading Rapid Process Improvement Workshops (RPIWs)
Learning How to Manage•RPIW Sponsor Status Report Outs•Quarterly Reviews•Performance Walls•Daily Management•Strategy Deployment
PHSA’s imPROVE Education Program
Lean Leader Certification
Lean Leader Certification Process
Co-requisite: Coaching Out of the Box
Build Capacity to Lead Lean
•200 plus PHSA Leaders on Lean Leader Certification Track•19 Senior Executive Leaders•20 Physician Leaders
imPROVE Productivity
•IMPROVEMENT WORK-13 Active Value Streams
-180 RPIWs completed as of March 2012
-4 3Ps and 8 IFDs completed for BC Children’s and Women’s Hospital Site Redevelopment
-105 5s completed
-12 Rapid Kaizen Events – using A3 thinking
PHSA Lean Management System Overview
MiddleManagement
SeniorManagement
Front LineLeaders
Front LineStaff
SW
Monthly Review
Takt / Hourly Shift / Daily Weekly Monthly
Work station Department Value Stream Organization
HourlyPerformance
Metrics
DepartmentDaily MgtBoard
Value StreamPerformance
Wall
OrganizationPerformance
Room
Daily Huddles Weekly Gemba
QualitySafety
DeliveryCost
Satisfaction
ProblemSolving
Root Cause&
CounterMeasure
Action Plan
Current &Future VSM
RPIWPlanning
StrategyDeployment
BreakthroughObjective
Vision
Daily Management Strategy Deployment
PHSA Strategic Objectives
1. Improving Quality Outcomes and Better Value for Patients.
2. Promoting Healthier Populations.
3. Contributing to a Sustainable Health Care System.
QUALITYCLINICAL
EFFECTIVENESS
SAFETYPATIENT AND
STAFF
DELIVERYACCESSIBILITY,
CONTINUITY, POPULATION FOCUS
COSTEFFICIENCY
SATISFACTIONCLIENT CENTERED
WORKLIFE
PHSA STRATEGIC DIRECTIONS: Creating Better Value and Outcomes for Patients, Contributing to a Sustainable Health Care System, Promoting
Healthier Populations.
Achieve standard practice by use of clinical practice standards adhered to 95% of time.
Eliminate all level 4/5 safety events arising as a result of our care.
Eliminate unnecessary waiting for all patients and care providers.
Reduce waste for both patients and those who provide care.
BCW achieves over 95% top rating for recommended placed for patient care and staff employment as compared to other hospitals.
Target: Year 1 (2011 – 2012) each
area will implement 2 clinical practice standards adopted at 95% reliability rate.
Target: Year 1(2011 – 2012)
from 97 per year to 50
Year 2 (2012 – 2013) from 50 to 20
Year Three (2013 to 2014) from 20 to zero.
Target: Year 1 (2011 – 2012)
50% Lead time reduction
Target: Year 1(2011 –2012) implement systems to retrieve quarterly data for all service lines.
BCWs Performance Walls
BCW Acute Maternity and NICU Performance Wall Review Weekly
BCW Executive Quality Council Performance Wall Review Monthly
BC Mental Health and Addiction Services Performance Wall Weekly Review
BCMHAS ED – Delivery Access Improvement
BCMHAS ED – Employee Engagement
2009 2011 Change3.68 3.63 -0.05
PHSA overall average score
Eating Disorders program score2009 2011 Change3.68 4.15 +0.47
Why Daily Management…• Lean improvement processes and daily management are
intertwined. To maximize improvement, you cannot do one without the other
TIME
IMPR
OVE
MEN
T
KK
K
K
K
K
K
K
K
S
S
SS
K: KaizenS: Sustain
Improvements slide when not sustained by daily management
BCCA Vancouver Center Ambulatory Clinic Daily Management Board
Who WhenAction
Incomplete order
OR
KPI name and a status “At a
Glance”- What we are
tracking.
Performance- How we are
doing and have been doing
Root cause and problem solving
- What issues are making us miss
target
Action plans- What we are doing
to improve or get back on track
Make Data Visual – Status at a GlanceQuality
Who WhenAction
Incomplete order
OR
Performance Tracking VisualQuality
Who WhenAction
Incomplete order
OR
Data is obtained from daily scorecard
% of incomplete or incorrect Patient Orders
0%
5%
10%
15%
20%
25%
30%
35%
40%
Tue-02/01
Wed-02/02
Thu-02/03
Fri-02/04
Mon-02/07
Tue-02/08
Wed-02/09
Thu-02/10
Fri-02/11
Mon-02/14
Tue-02/15
Wed-02/16
Thu-02/17
Fri-02/18
Mon-02/21
Tue-02/22
Wed-02/23
Thu-02/24
Fri-02/25
Mon-02/28
Tue-03/01
Wed-03/02
Thu-03/03
Day
%o
f o
rde
rs
Actual% on time Target
% Patient Calls to Voicemail
Unit Staff enter the data daily
Problem Identification and AnalysisQuality
Who WhenAction
Incomplete order
OR
Action Plan – Kaizen NewspaperQuality
Who WhenAction
Incomplete order
OR
BCCA Daily Accountability Huddle
PHSA Successes
•Leadership driven.
•Managerial fortitude to make tough discussions and stay the course in the political environment.
•Begin with outside experts who have deep knowledge of Lean to establish the discipline.
•BUT build internal capability and infrastructure to support leaders for application in everyday work.
PHSA Lessons Learned
•We have just begun to understand the depth of lean.
•Will not sustain the gains without the foundation of a Lean Management System – Daily Management and Strategy Deployment.
•Shift in the way leaders think, what they see, what they do will shift the culture.
• $2.8 billion annual funding • 22,000 staff • 3 Communities of Care• 556 locations including
• 13 hospitals• 3 diagnostic and treatment centres• 15 community health centres
Vancouver Coastal Health (VCH)
Promote Better Health
for our Communities
Develop the Best
Workforce
Provide the Best Care
Innovate for Sustainability
People First
VCH True North Goals
VCH Lean: 3 Areas of Focus
Strategy Deployment
What do we improve everyday?
Lean Management
How do we manage to improve everyday ?
Continuous Improvement
How do we improve everyday?
Source: Staying Lean (Hines, 2011)
Process management
Technology, tools and techniques
Above the line: visibleBelow the line: enabling
Strategy and alignment
e.g. Birth Center Pilote.g. Regional Patient
Transfere.g. Returning employees
to work
e.g. Strategic Deployment with the various Communities of Care
Above the line: visibleBelow the line: enabling
The Iceberg Model
Leadership
Behavior & Engagement e.g. Lean Management across the various leadership teams
Lean is About CULTURE Change
Evolution of Lean Education at VCH
2006/7 –20010/11 2011/12 2012/13
Upfront Lean education for project teams
JIT Education for project teams
-Lean basics-5 steps to Lean Thinking-Current & Future State Mapping, etc.
Development of formal Lean education program
Development and implementation of Lean Management education program for senior leaders
Integration with other Management Development programs
Lean Management Education for front line leaders and staff
Development of model cells
Implementation of Lean Management system
Coach Lean Management in real time
VCH Lean Education Programs
Intro to Lean
Recommended for: All Staff, Leaders &
Physicians
Value Stream Mapping & A3
Problem Solving
Recommended for:All Staff, Leaders,
Physicians
Leading Lean Projects
Recommended for: Emerging Leaders,
Supervisors, Coordinators Project
Champions
Lean Management
Recommended for: Directors, Managers,
Supervisors, Coordinators,
Physicians
Peop
le
Daily Status Sheet
Exchanges
Continuous Improvement
Huddles
Breakthrough Improvement
Lanes
Proc
esse
s
Standard Work Audit Board
Value Stream Mapping
A3 Problem Solving
Understand & Improve the Business
Performance Dashboard
Leader Standard Work
Managing Daily to Continuously Improve and to Add Value to Every Patient, Client, Resident & Customer Experience
Covered in Lean Management Introduction Course
VCH Lean Management System
Inch Deep, Mile Wide
Mile D
eep, Inch Wide
Educate many and support partial implementation until critical mass is reached?
Or
Intensively educate and support a few to full implementation?
Approach to Implementation: Wide or Deep
Educate and implement with senior leaders
first?
Educate and implement in
local areas with small vertical teams first?
Or
Approach to Implementation: Top Down or Bottom Up?
COOs, Directors and Managers Participate in Lean Management
Course
Strategy Deployment at each Community
of Care
Front Line Leaders participate in Lean Management Course
Establish Model Cells in Each Community of Care and in Corp &
Regional Areas
Implementation of Lean Management in Operational Areas
Implementation of Lean Management in Corporate and
Regional Areas
Lean Education Coaches and internal experts continue to teach, mentor and refine Lean Management System at local levels
Feedback to and Education of Senior Executive Team &
Board
VCH Approach to Lean Management
Before After
Leader Standard Work for Manager
Role/LevelStandard Work Accountability Processes
Manager 60-80% of job is standard work processes as outlined belowDaily huddle with all team leads (15 min) using daily status sheets to review targets/ issues/ day to day operationsDaily huddle with staff using visual board; just in time problem solution and standard work development; barrier resolution; focus on targets and delays; reds from daily meetings for resolution.Coaches staff in solving problems using PDSAResolution of cross team issues; Ensures their area based visual boards are current Resolves issues raised by Team Leader within 24 hrsGemba walk
Responsible for coaching Team Lead in problem solvingTo remove barriers from team functioningAddress complaintsCustomer relationships / Education w/ unions and patients/ clients/ residentsContinuous development for team
Ensures timely response to everyday Lean ideasEnsures Team Leader addresses everyday Lean ideas within time framesEnsures program visual boards current and usedEnsures regular engagement with staff related to improvement ideas
Leader Standard Work
Breakthrough Improvement LanesRichmond Birth Center
Daily Tracking SheetBanfield Pavilion
Daily Tracking SheetBanfield Pavilion
Leadership Team Learning Together: Banfield Breakthrough Lanes
Standard Work Audit BoardRichmond Birth Center
RH Birth Centre
Staff’s suggestion for continuous improvements
Improvement HuddleRichmond Birth Center
• Multi-faceted approach fits VCH organizational cultures
• Solid education program provides strong foundation for sustainable Lean Management System
• Leadership experiencing renewal and hope
• Deep learning about root causes
VCH Successes
• Establish infrastructure to provide education early
• Develop model cells early
• There is a significant learning curve in applying a Lean Management System in community, corporate and regional areas
• Lean project coordinators may also need additional education in order to coach leaders in Lean management
VCH Lessons Learned
The complexity of modern healthcare
requires a simple and direct management
approach.
Caution!
If we as leaders focus only on the tools of Lean Management, we will not shift the culture to continuous improvement.
A Shift in the Management Process
Source: www.lean.org
Three Keys to Leadership
Coaching Questions
1. What is the target condition?
2. What is the actual condition now?
3. What obstacles are now preventing you from reaching the target condition? Which ones are you
addressing now?
4. What is your next step? (start of the next PDSA)
5. When can we go and see what we have learned from taking that step?
Source: Toyota Kata (Rother, 2010)
Leaders Develop Problem Solvers
Source: Toyota Kata, (Rother, 2010)
What is Lean?
•Lean is a practice, not a theory: there is no roadmap, project plan or strategy. There are no miracles other than going to the front line often, visualizing one’s challenges and patiently teaching people to solve their own problems.
•To succeed in Lean, respect for people is as important as continuous improvement.
Source: The Lean Manager (Balle, 2009)
1. What would you need to change in your current management system to support Lean Management in your organization?
2. What are the implications for leadership development in healthcare?
3. What are the risks in not doing this?
4. What are the top 3 ideas that you are going to act on when you go back to work?
Discussion Questions
References
Balle, Michael and Balle, Freddy. The Lean Manager: A Novel of Lean Transformation. Cambridge, M assachusetts: Lean Enterprise Institute Inc., 2009.
Mann, David. Creating a Lean Culture: Tools to Sustain Lean Conversions. New York: Productivity Press, 2010.
Rother, Mike. Toyota Kata: Managing People for Improvement, Adaptiveness, and Superior Results. New York: McGraw Hill, 2010.
Womack, Jim. Gemba Walks. Cambridge, Massachusetts: Lean Enterprise Institute Inc., 2011.
Additional ReadingKenney, Charles. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. New York: Productivity Press, 2011.
Toussaint, John and Gerard, Roger. On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry. Cambridge, Massachusetts: Lean Enterprise Institute Inc., 2010.
Wellman, Joan; Hagan, Patrick and Jeffries, Howard. Leading the Lean Healthcare Journey: Driving Culture Change to Increase Value. New York: Productivity Press, 2011.
Useful Websites
•Lean Enterprise Institute –www.lean.org
•Healthcare Value Network -www.healthcarevalueleaders.org
•Lean Enterprise Academy –www.leanuk.org
•Mark Graban’s Lean Blog –www.leanblog.org
Contact Information
Margaret Seppelt BSN, MBA Provincial Health Services [email protected]
Cindy Priddy BS, MA, MCS Vancouver Coastal Health [email protected]
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