Pursuing ExcellenceQuality and Safety as the New Currency

Richard P Shannon, MDFrank Wister Thomas Professor of Medicine

Chairman, Department of MedicineUniversity of Pennsylvania

Perelman School of Medicine

Session Objectives

• Explore the importance of organizational values as the foundation for high performance

• Understand the characteristics of high performing organizations

• Examine the application of such principals to the elimination of harm as represented by hospital acquired infections and unexpected deaths.

• Determine the business case for quality

Where is Academic Medicine in the Journey toward Quality and Safety?

• Lack of clearly specified and audacious goals• Infatuation with reportable not actionable

data• Awash in meaningless measures• Lack a common, disciplined problem solving

system (Hawthorne effect)• No room for learning• Confuse effort with success

AMCs and US Healthcare System

Why do we need “Leadership Leverage” ?

• Quality improvement has been about “projects.” We have become good at making improvement happen for one condition, on one unit, for a while

• We haven’t learned how to get measured results, quickly, across many conditions for the whole organization

• Quality is never an accident; it is always the result of high intention, intelligent direction and skillful execution; it requires a commonly shared, disciplined problem solving approach embraced not in the conference room but at the point of care.

A “Project”

System Level Aim

• “If we solve our health care spending, practically all of our fiscal problems go away,” said Victor Fuchs, emeritus professor of economics and health research and policy at Stanford. And if we don’t? “Then almost anything else we do will not solve our fiscal problems.”

The Sense of UrgencyHealth Care and the Nation’s Economy

Healthcare Spending and Social Good

• US spends 18% of the GDP in healthcare• CMS accounts for 20% of the total

government spending-8x more than on education-12x more than food aid-30x more than on law enforcement-78x more than conservation-87x times more than water supply-830x more than on energy conservation

High Performing Organizations• High performing organizations are the best in

class• They achieve high performance not

necessarily through technological advances but through complete engagement of all the wisdom and skill embedded in each worker

• These organizations and their leaders never stop learning

Spear Chasing the Rabbit

Dynamics of HPOs

• Cope with complexity by continuous focus on learning more about how to improve the work they do.

• Its is not about knowing the right answer, its about discovering the right answer.

• Nothing is ever good enough

Spear Chasing the Rabbit

The Four Capabilities of HRO

• Specifying work to capture existing knowledge• Swarm and solve problems to build new

knowledge (avoid “information perishability”)• Share that knowledge throughout the

organization• Lead by developing these capabilities in all

workers

Spear Chasing the Rabbit

Leaders in HPOs

• Set clear and unambiguous expectations• Amazing problem solving capabilities• Empower and create systems that provide

answers….• How they spend their time reflects their

values• Take away all the excuses as to “Why not?”

Spear Chasing the Rabbit

Levers of Waste

Don Berwick

•Harm•Overtreatment•Defects in care delivery•Defects in care transitions•Excess administrative costs•Fraud and abuse

Why Safety?

• It is unassailable• Harm violates our professional duty• Harm is the elementary form of waste• It is valueless• It can be eliminated

Current US Estimates

• 5-10% of inpatients acquire an HAI• 1.7 million HAIs annually• 99,000 deaths• Estimated costs:$28.4-33.8 billion• It is 27X safer to work at Alcoa than it is to work

into a US hospital

Safer?

HAI in Pennsylvania 2012

23,287 HAI (1.2%)

Patient Outcomes

An Audacious and Unassailable Goal

• Can the elimination of harm (hospital acquired infections, medication errors, readmissions) serve as a starting point for reducing unnecessary costs (waste) in healthcare?

• Does it fulfill our professional duty to do no harm and to be good stewards of finite resources?

Problems With Bench MarkingThe Difference Between Reporting and Actionable Data

01 Q3 01 Q4 02 Q1 02 Q2 02 Q3 02 Q4 03 Q1 03 Q20

1

2

3

4

5

6

7

8

9

10

CCU/MICU

NNIS

PRHI

What Does 5.1 infections/ 1000 line days Really Mean??

• 37 patients / total of 49 infections• 193 lines were employed (5.2 lines / patient)• 1753 admissions• 1063 patients had central access for more than 12 hours• 1 out of 22 patients with a central line became infected.• We were reporting only half the actual infections (not including femoral

line infections!!)• Two-thirds of the infections involved virulent organisms. Twenty percent

were MRSA• 19 patients died (51%)

Journal of Quality and Patient Safety 2006;32:479

Personal Stories

• 22 yo. woman, a single mother of a 2 year old child, presented with relapsing acute myeloid leukemia.

• Following re-induction with a highly toxic chemotherapy regimen, she is found to be in complete remission.

• Day 18, she develops fever, chills and hypotension. BC grow staph aureus from her Hickman catheter.

• In retrospect, the unused lumen of her triple lumen catheter had cracked and been repaired.

• The cracked lumen-repair process was common place despite evidence that it was associated with a27% risk of infection

• RCA revealed unspecified understanding about flushing unused catheters and that there was a small area on the lumen where a clamp should be re-enforced.

• The patient spend an additional 17 days in the hospital, away from her child.

• She died 27 days after discharge.

Current Conditions

Decode: 37 CLABS(July 2002-June 2003)

PRHI Central Line Data

Observations of Dressing Changes

Root Cause Analysis

Solve to root cause in real timethe origins of CLABS in

MICU / CCU

Counter Measures GeneratedBy the People That Do The Work

Eliminate CLABSIn MICU/CCUIn 90 days

Reassess ResultsGenerate AdditionalCounter Measures

The Work of Physician LeadersRounding on Sick Systems

• Chief complaint• Present illness• Physical exam/diagnostic

test

• Therapeutic intervention• Clinical course• Natural history

• Assessment of outcome

• What’s the problem ?• How is work currently done?• What defects are

encountered in the work?• Intervene to eliminate

defects• Create a target condition• Measure what actually

happens• Gap analysis

Rounding on Sick patients Rounding on Sick Systems

The Current Condition of VariationSteps 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

Enter Glove Visual Set up Wipe Flush Draw Wipe Vac Draw Draw Prob. Vac Wipe Flush Prob. Wipe Cap DiscardGlove Flush Wipe Vac Draw Wipe Draw Draw Vac Wipe Flush Wipe Cap DiscardLabel Docum.Seal Wash

Glove Gow n Enter Alarm Set up Cap Wipe Vac Draw Draw Draw Alarm Vac Wipe Flush Wipe Alarm Glove Label Docum.send

Enter Set up Wipe Flush Waste Draw Wipe Draw Trans. Draw Draw Draw label Seal Docum.Seal Glove Exit

Labels Supplies Enter Set up Purell Alarm Disc. Tubalcohol Un- Cap BD Wipe Vac Draw Draw Draw Draw Vac Wipe Flush Discardlabel Seal Prob. SuppliesAlarm alcohol Disc. TubUn- Cap Wipe Vac Draw Draw Draw Vac Flush DiscardDisc f lushWipe Rec. Tublabel Seal DiscardExit Wash send

Supplies Labels Glove Enter Med Set up Wipe Flush Alarm Vac Draw Draw Draw Vac Wipe Flush Prob. (untag- line)DiscardGlove Alarm Label Docum.Seal send

Supplies Enter Glove Unw rapAlarm Flush Vac Draw Draw Draw Vac Wipe Flush Rec. TubDiscardlabel Wash send

Enter Glove Visual Set up Wipe Flush Wipe Vac Draw Draw Draw Wipe Vac Wipe Flush Cap DiscardGlove Label Seal Wash send

Enter Glove Visual Alarm Wipe Flush Prob.( no blood)Flush Vac Draw Draw Draw Vac Wipe label Discard

Supplies Enter Glove Visual Set up(bed) Alarm Flush Vac Draw Draw Draw Draw Vac Wipe Flush Wipe Flush Glove Docum.Label Seal

Labels Supplies Purell Glove Enter Alarm Set up(bed) Disc. TubUnw rapWipe Flush Draw Wipe DiscardDraw Trans. Fill Fill DiscardWipe Flush Rec. TubDiscardlabel Glove Seal send Wash

Labels Supplies Glove Enter Alarm Set up clamp Disc. TubWipe Flush Draw Wipe Vac Fill Fill Fill Fill clamp Vac Wipe Flush clamp Rec. Tubclamp DiscardAlarm label Exit send Glove

Labels Supplies Label Docum.Gow n Glove Enter Set up (TOWEL ON BED)Alarm Wipe Flush Draw Wipe Draw Needle Wipe Draw Needle Wipe Flush DiscardSyr Fill Fill Syr Fill Fill Fill DiscardGlove Exit Wash Seal send

Labels Supplies Unw rapDocum.Wash Enter Set up(bed) Glove Wipe Flush Vac Fill Fill Fill Fill Fill Fill Vac Wipe Flush Discardlabel BD label BD Wash Exit Docum.Seal send

Labels Supplies Enter Unw rapSet up(bed) Wipe Flush DiscardWipe Draw Trans. Fill Fill DiscardWipe Draw Trans. Fill Fill Fill DiscardWipe clamp Flush DiscardPurell Exit Docum.Label Seal send

Labels Supplies Wash Unw rapGow n Glove Enter Alarm Wipe Flush Draw Draw Wipe Alarm DiscardSyr Fill Fill Fill Syr Fill Fill label BD DiscardGow n Glove Exit Seal send

Enter Gow n Purell Glove SuppliesProb. Glove (off)Gow n (off)Wash Exit SuppliesEnter Set up(podium) Purell Gow n Glove Stock Explain Alarm Un- Cap StopcockVac Fill Fill Flush Cap StopcockAlarm Gow n Glove Wash Exit Glove Label Seal send

Gow n Enter Glove SuppliesAlarm Set up(bed) StopcockUn- Cap Vac Fill Fill Fill Fill Fill Syr Flush w ith green tube)Vac Cap Discardlabel Gow n Glove Purell Exit Seal send

Supplies Un- Cap Wipe Syr Fill Fill Wipe pump DiscardSyr recap

Order LabelPurell Glove SuppliesExplain Alarm Line Set up(bed) (ABG &4x4)Un- Cap Draw w asteDraw ABGWaste (gauze)Flush Cap Flush DiscardPurell Spec/gloveLabels Label Seal send

Purell Labels SuppliesGlove Alarm Line Set up(bed) 4x4)AssembleVacUn- Cap Cap/gauzeVac Draw w asteFill (purple)Flush w ith green tube)Discardlabel DiscardWash Spec/gloveProb. Tries to sendSeal send

Glove Supplies Set up(bed) 4x4)Un- Cap Vac Draw w asteFill red tubeAlarm ABG syrCap ABGFlush DiscardVac Glove Spec/glovePurell Labels Label Seal send Seal send

Comp. Purell SuppliesAssembl VacAlarm Glove StopcockUn- Cap Cap/ infusion pumpVac Draw w asteFill (tiger top)Vac Flush Discard stop in vacCap stopcockAlarm Discard Glove Purell Labels Label Seal send

Set up Flush Vac Fill Fill Flush Un-Gow nSuppliesWipe Draw Fill Flush Wipe Syr Fill Discard

Enter Wash SuppliesWipe Unw rapDraw Trans. Wipe bottleFill Wipe bottle 2Fill Wipe Vac Fill Wipe Unw rap flushWipe Flush Wipe Syr Wipe Rec. TubAlarm Discard Labels Label Seal send

Supplies Gow n Glove Wipe Flush Wipe SuppliesGow n Glove Wipe Vac Fill Syr Wipe Flush Discard bed TPA

Labels Supplies Gow n Glove Set up Explain SuppliesAlarm Line StopcockUn- Cap Assemble vacVac Fill Fill Fill Stopcockvac Gauze on portSqueezeCap StopcockFlush Discard waste gauzeAlarm Discard label Discard other workUN-GloveWash Glove Seal send

Glove Gow n Enter

Prob.(look for Alarm Glove

Supplies

Set up (bed)

Unw rap Visual Vac

Waste (tube) Fill Fill Fill

Discard (vacut Syr Flush Cap

Discard (sharp

Discard (red)

Discard (w hite UN-Glove

De-Gow n Wash Label Seal send

Glove Gow n Enter

Prob.(look for Flush Visual Alarm Flush

Waste (10 cc.) Draw StopcockCap Flush

Alarm (restart)

Discard (sharp

Discard (red)

Discard (w hite UN-Glove

De-Gow n Wash Label Seal send

Order Gow n Glove EnterSupplies

Set up (bed) Visual

Stopcock Syr Waste

Cap (hold)

Syr (remove)

Prob. (cap on

Syr. (in stopc Draw

Prob. (dirty cap Unw rap 4x4Flush

Cap (back on) Flush

Discard (sharp

Discard (red)

De-Gow n Purell Label Seal send

Wash Supplies GloveSet up (bed)

Unw rap

Remove air Wipe Vac Fill Fill

Vac (remove) Wipe Flush Clamp Alarm

Discard (sharp

Discard (red)

Discard (w hite

Label (pink, supply

Label (pt., at desk) Docum.Label

Prob. (no tube)

call blood bank wait

call CDR wait

1st tube arrive Seal send

2nd tube arriveProb.

(look for labels) Glove

Supplies

Stopcock

Set up room (Move

assemble vac

Stopcock

Cap (remove) Vac Fill Fill

Stopcock Flush Cap Flush

Stopcock

Purell GloveSupplies

Prob. (look for UN-Glove

Supplies (Omni Purell Glove Alarm

Set up (bed) Cap

Syr (3 cc)

Prob. (diff. draw

Prob. (manipulate

Syr (ABG) Draw

Unw rap 4x4 Flush Waste Cap

Clear air from

Discard (w hite

Discard (sharp Label

UN-Glove Purell

Order LabelPurell

Prob. (w ait for Purell Glove Alarm BD

Set up (bed) Cap

Unw rap 4x4

Syr (3 cc) Waste

Syr (ABG)

Cap (hold)

4x4 (hold) Waste Cap

Clear air from

Discard (sharp

Discard (red)

UN-Glove Purell Label Seal send

Purell GloveSupplies

Unw rap 4x4

Unw rap 4x4 Cap Waste Fill Fill Fill

Prob. (manipulate

Cleared line at

Cleared line at

Discard (sharp

Discard (red)

UN-Glove Purell Label Seal send

SuppliesSet up (table) Wipe Vac Waste Fill Fill Fill

Vac (remove) Wipe Flush Clamp label BD Seal send Docum.

Enter Explain Alarm Wash Glove Set up room (Move iv pole - move chair)Supplies (w ipes in room)Unw rap

Remove air Wipe UN-Cap Flush

UN-Clamp Vac

Fill (w aste)

Supplies (stude

Set up (bed) Fill Fill Vac Flush ClampWipe

Discard (sharp

Discard (red)

Discard (w hite UN-GloveWash other workLabel Seal send

Purell Wipe Clamp Attach Flush unclampFlush

Fill (w aste)

Discard (sharp Explain

Assemble Vac Fill Fill Fill BD Wipe Flush Clamp Docum.Wipe Disconnect tubingExplain Label Seal Prob- no tubes told sec.send

Supplies Wash Glove Set up room (Move iv pole - move chair)Wipe Flush

Fill (w aste)

Discard (sharp clamp Fill

Discard (sharp Flush Reconnect tubingDocum.Cap Explain label Seal Prob- no tubes sec calling for tubes

Supplies Purell Enter Glove (Purple)Alarm Flush Wipe vac Waste Fill Alarm Fill Flush Alarm

Discard (sharp UnGlovePurell labels Label ice Seal send

Wash Enter Set up bedGlove prob SuppliesWipe vac Flush Waste Fill Fill BD Fill label Wipe Flush clamp Wipe Flush label

Discard (sharp Exit Wash

Labels Supplies Glove Gow n Set up room tableAsemble vacUnw rapWipe Flush Waste Wipe vac Fill Fill Fill Unw rapWipe Flush clamp

Discard (sharp

Discard (red)

Discard (w hite BD label

1) Set up work Hand Hygiene Open Drape Open Dressing Kit Drop Biopatch Wash or Purell Space

2) Prepare Adjust Bed Don Masks Clean Gloves People (nurse) (patient)

3) Remove Remove with alcohol Discard Trash Wash Hands Dressing

DRESSING CHANGE STANDARD WORK

5.) Apply New Apply Outline Apply Seal Apply Strips in Biopatch Dressing Dressing Dressing X and label

4.) Clean site Apply Chloraprep Allow to dry Sterile 30 seconds 30 seconds gloves

Central Line AssociatedBlood Stream Infections

0

5

10

15

20

Months

Nu

mb

er o

f In

fecti

on

s

Value Stream MappingA Way to Identify and Correct Defect

• Types of catheters associated with HAIsintravenous cathetersendotracheal tubesbladder catheterssurgical sites

• Steps in Standard workPlacing Maintaining Manipulating

28

2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

BSI

VAPS

MRSA

Fiscal Year

Reductions in HAIs

Journal of Quality and Patient Safety 2006;32:479

CCU/MICU and HAIA Big Return on Investment

• Total Operating Improvements CLAB= $1,235,765 (2 years)VAP= $1,003,162 (1 year)MRSA= $ 295,342 (1 year)

• Highmark PFP = $3,100,000 (2 years)• HAI elimination Initiatives = +$5,634,269• Investment = $85,607 • 388 additional ICU admissions • 57 lives saved

Penn MedicineThe Journey of 1,000 Days

• Reduction in Variable Costs attributed to CA BSI elimination:$10,923/case

• Total: $3,823,050• Reduction in LOS: 10.7 days• Additional admissions: 623• Additional revenue: $3,613,400• IBC P4P: $3,200,000

• Total Financial Improvement: $10,636,450• Lives saved 65

Mortality 0.6% 12.3% 20X

Human Costs of CA-BSI• 37 year old video game programmer, father of 4,

admitted with acute pancreatitis secondary to hypertriglyceridemia.

• Day 3: developed hypotension, and respiratory failure• Day 6 : fever and blood cultures positive for MRSA

secondary to a femoral vein catheter in place for 4 days.

• Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy

• Day 86: Discharged to nursing home

Shannon RP: AJMQ

6 86

CLAB

Day 1

2/07/02Transfer 5/04/022/12/02M. S.

T o ta l C o s t o fP a tien t S tay2 4 1 ,8 4 3 .8 2

T o ta l C o s t a f te rC L AB

2 2 9 ,3 8 1 .0 8

T o ta l C o s t b ef o r eC L AB

1 2 ,4 6 2 .7 4

T o ta l Attr ib u tab leC o s t

1 7 0 ,5 6 5 .1 2

N o t R ela ted toC L AB

5 8 ,8 1 5 .9 6

M I C U S er v ic e1 0 6 ,7 3 7 .5 6

P r im ar y to C L AB5 2 ,9 1 4 .0 9

S ec o n d ar y to C L AB1 0 ,9 1 3 .4 7

T o ta l Attr ib u tab leC o s t0 .0 0

N o t R ela ted toC L AB

1 2 ,4 6 2 .7 4

T o tal C o s t A ttrib u tab le toIn fe c tio n

1 7 0 ,5 6 5 .1 27 0 .5 3 % o f T o tal

T o ta l Attr ib u tab le C o s tBef o r e C L AB

0 .0 0

T o ta l Attr ib u tab le C o s tAf ter C L AB1 7 0 ,5 6 5 .1 2

P r im ar y to C L AB0 .0 0

S ec o n d ar y to C L AB0 .0 0

The Impact of CA-BSI on Gross Margin

DRG 204/2721(n=3)

DRG 191(n=3)

DRG 483(n=2)

Case 1

Acute pancreatitis

Pancreatitis w cc

Pancreatitis w trach

Revenue ($) 5,907 99,214 125,576 200,031

Expense 5,788 58,905 98,094 241,844

Gross Margin

119 40,309 27,482 -41,813

Costs attributable to CA-BSI

170,565

LOS 4 38 41 86

http://images.google.com/imgres?imgurl=http://www.uphs.upenn.edu/radiology/images/logos/HUPlogo.jpg&imgrefurl=http://www.uphs.upenn.edu/radiology/educ/CE/cecourses/penncourse2109.shtml&h=709&w=625&sz=63&hl=en&start=12&tbnid=k_e2rP4D_Lck7M:&tbnh=140&tbnw=123&prev=/images?q=University+of+Pennsylvania+School+of+Medicine&svnum=10&hl=en&lr=&sa=G

UHC Mortality Rank 2012: 26th

• There were 804 deaths at HUP• There were 462 deaths attributed to Medicine• There were 49 deaths among electively

admitted patients• There were 89 deaths among patients with

low/moderate severity of illness index• 59% of deaths had an in-hospital complication

A Matter of Life and Death

• Who died last night?• Was it expected or unexpected?• If unexpected, what happened?• Create clinical vignettes on all deaths• Were there any “bumps in the night?”

MICU transfers

Unexpected Deaths15-20%

• Aspiration Pneumonia SIT UPPatients at RiskInterventions

• Delays in Diagnosis and TreatmentHeart failureLiver Failure

UHC Mortality

2009 2010 2011 2012 20130

100

200

300

400

500

600

700

800

900

1000

O/EDeaths

0.89 0.86 0.81 0.79 0.62

468 453 464 453 372

Summary• High performing organizations are best in class based upon values

based leaders, disciplined problem solving systems and a commitment to habitual excellence.

• Habitual excellence requires continuous improvement and continuous improvement requires continuous learning as to how to execute our work better.

• The elimination of harm and unexpected deaths is an unassailable goal and illustrates the importance of values as a the starting point on a journey toward excellence in Medicine.

• Coupling the business case for quality with performance improvement can accelerate the progress.

• Resources liberated from the elimination of waste as fuel the virtuous cycle of our academic missions.

If Not us, Who?

Somebody has got to do something…

…its just incredibly pathetic that it has to be us !!!

Jerry Garcia The Grateful Dead

The Barriers to Change

There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.

Niccolo Machiavelli 1513

Primum Non Nocere

78%

19%

0%

20%

40%

60%

80%

100%

2001 2002 2003 2004 2005 2006 2007

Health Insurance Premiums Workers' Earnings

Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, 2001-2007

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April).

A new revolution….

Build a Parking Garage or Fix the Care Process?

Not more…better Not volume….value

Modifying the Patient Experience

14 days 57 min22

min31

min23

min

Call Wait for App Travel Park Reg Wait VS Wait MD CO Tests Exit

18min

17min

14min 97 min

18min

4:05

77 min

$32 parking

7 days 57 min 15min

7min

20min

11min 45 min

14min

2:02 $8 parking

37 min

­Patient visits from 7-9/session­ On –Time Performance­ Patient satisfaction (waiting) Lag days

US Navy’s Nuclear Submarine Program

• 200 nuclear powered ships launched • 5,700 reactor years of operation• 154 million miles underway• Not a single reactor related casualty or escape of

radiation• The leader: Admiral Hyman Rickover and the

discipline of specifying expectations and the developer of incident reports

• Leaders and learning are indispensable

What Leaders think matters…What leaders do matters more

• Your personal leadershipSetting audacious goalsPractice don’t espouse Values

• Your leadership systemLessons from highly performing organizationsThe importance of a common disciplined problem

solving

• TransparencyPersonal stories

The business case for quality51

Begin with a Value PropositionOur Contract With Society

• Commitment to professional competence• Commitment to honesty with patients• Commitment to patient confidentiality• Maintenance of appropriate relationships with patients• Commitment to improving quality of care• Commitment to improving access to care• Commitment to scientific knowledge• Commitment to trust by managing conflict of interest• Commitment to professional responsibilities• Commitment to the just distribution of finite resources

Primum non nocere

will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to them anyone

will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

Values Trumps Process

Improvement vs. Habitual Excellence

2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

300

350

400

Infections

1,000 days

Leaders are responsible for everything in an organization, especially what goes wrong.

Paul O’Neill

Leadership Mentor