weekly global covid-19 update: part 2
TRANSCRIPT
Presented byVidal Seegobin, Global Forum for Health Care Innovators
What you need to know in 30 minutesWeekly Global COVID-19 Update: Part 2
April 20, 2020
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Today’s Research Expert
Vidal SeegobinPractice Manager, International Research
Vidal is a practice manager on the Global Forum for Health Care Innovators—Advisory Board International's health care strategy programme. Prior to joining the Advisory Board, he worked as a researcher on disease surveillance and pandemic response. He holds a master's degree in international economics from American University and a bachelor's degree in international business from Carleton University in Ottawa, Canada.
[email protected] @SeegobiV
Vidal photo
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Source: Batia A, “Trajectory of COVID-19 Confirmed Cases,” updated 17 April 2020; Minutephysics, “How To Tell If We're Beating COVID-19,” Youtube.com, 27 March 2020; “Coronavirus Disease (COVID-19) – Statistics and Research,” updated 16 April 2020.
COVID beginning to drop off in US and Western Europe
Advisory Board interviews and analysis.
10
100
1,000
10,000
100,000
100 1,000 10,000 100,000 1,000,000
AustraliaSouth Korea
Canada
France Italy
Spain
U.S.
500,000
Total confirmed cases
New
cas
es in
the
past
wee
k
Country Total deathsper million
Spain 409
Italy 367
France 274
UK 202
US 100
Germany 46
Canada 32
South Korea 4.5
Australia 2.5
New Zealand 2.2
New cases vs total cases amplifies which countries are deviating from exponential growth ‘conveyer belt’
COVID grows at the same exponential rate in nearly all countries
Exponential growth rate
Countries drop off ‘conveyer belt’ as growth in cases is no longer exponential
New Zealand
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Source: “Here are the businesses that can start reopening in Italy,” The Local, 14 April 2020; Woods A, “Spain loosens coronavirus restrictions as nearly 300,000 return to work,” New York Post, 14 April 2020; “Coronavirus: Austria and Italy reopen some shops as lockdown eased,” BBC News, 14 April 2020; Murray A, “Coronavirus: Why Denmark is taking steps to open up again,” BBC News, 12 April 2020; “Coronavirus in Berlin: the current situation, how to prepare and more,” All About Berlin, 16 April 2020; Berglund N, “Norway cleared to gradually reopen,” newsinenglish.no, 7 April 2020; Němec L, “Breaking: Czech government outlines five-step plan for re-opening shops, restaurants,” Expats CZ, 14 April 2020; Sills B, “How European countries plan to reopen their economies from the coronavirus lockdown,” Fortune, 14 April 2020; Norman G, “Switzerland announces dates for its economy to start reopening during coronavirus outbreak,” Fox News, 16 April 2020.
Only a few countries starting with health careAs Europe reopens, variation in which measures lifted first
Advisory Board interviews and analysis.
Country Date of first lift First measures lifted Future plans to reopen
Italy 13 April Bookshops, children's clothing shops, dry cleaners, laundromats all madeessential businesses; most manufacturers reopening
Several regions (e.g., Lombardy) delaying opening these industries
Spain 13 April 300,000 people who cannot work from home (incl. construction and manufacturing industries) allowed to return to work in Madrid NA
Austria 14 April Shops <400 m2, hardware stores, and garden centres can reopen Larger shopping centres opening on 1 May; targeting mid-May for restaurants and hotels
Denmark 15 April Children aged 11 and younger return to schools and nurseries/day care; Hospitals start to conduct non-critical procedures NA
Norway 20 April Day care centers can re-open; Lift on Hytte ban;Opticians and physiotherapists can begin operating
Hair and skin-care salons, high schools begin reopening on 27 April; Cultural and sporting
events banned at least until 15 June
Czech Republic 20 April Farmers markets, trade shops, car shops, outdoor athletic areas for
professionals (without spectators), and weddings of up to 10 peopleFive-part plan reopens country over April and May, with the last restrictions lifted on 8 June
Germany 20 April Bike shops, garages, bookstores, and other stores less than 800 m2 can reopen Schools to begin reopening on 4 May; all “major events” forbidden until 31 August
Switzerland 27 AprilHospitals to resume non-urgent care and outpatient procedures, such as dental work and physical therapy; hairdressers, massage studios,
hardware stores, garden centers allowed to reopen
Primary schools and shops opening on 11 May; Secondary schools, vocational colleges,
universities, and museums opening on 8 June
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Source: “Malaysia turns to coronavirus antibody tests to supplement laboratory checks”, WHBL, April 14, 2020; T You, “Chinese police wear smart helmets equipped with AI-powered infrared cameras to detect pedestrians with fevers as they patrol the streets amid coronavirus crisis”, Daily Mail, March 4, 2020; Singapore Government, “Help speed up contact tracing with TraceTogether”, Gov.sg, March 21, 2020.
Solutions needed for three unanswered questions to phase out social distancingWhat do we need to know if we can reopen?
Who is immune? How is it spreading?Who has it and doesn’t know?
Antibody testsTo understand community spread and immunity levels in the population
What is needed to reopen,
state-by-state
What’s in the way of doing
more?
Disease surveillanceTo scan populations broadly for early symptoms and collect data
Scaled contact tracingTo isolate those who may have been exposed to symptomatic people
TraceTogetherSingaporean app tracks contact between people using phone Bluetooth
Where it’s already
happening
Smart helmetsChinese police wear smart helmets equipped to check pedestrians for fevers
Few commercially available, government-approved tests
MalaysiaAntibody tests used in conjunction with PCR1 tests during quarantine periods
Training and deploying newly idled government workers
Potential infringement on personal privacy laws
Advisory Board interviews and analysis.
1. Polymerise chain reaction.
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Source: C Hodgson and G Parker, “UK government admits Covid-19 antibody tests don’t work”, Financial Times, April 6, 2020; S Jones, “Coronavirus test kits withdrawn in Spain over poor accuracy rate”, The Guardian, March 27, 2020; G Chazan and D Mancini, “Germany to run Europe’s first large-scale antibody test programme”, Financial Times, April 9, 2020.
Progress yet to be made before promise of antibody tests can be realisedSerology testing has hit bumps in the road
Advisory Board interviews and analysis.
Effectiveness of serology tests still unknown1
32,000Blood samples in Germany will be analysed as part of antibody test programme
38,000Beaumont Health employees in a study on health care worker susceptibility and antibody response
Presence of antibodies doesn’t guarantee immunity 2
Challenges with serology tests for Covid-19
Large-panel antibody studies underway
"We simply don't know yet what it takes to be effectively protected from this infection."
Dawn Bowdish, Professor Pathology and Molecular Medicine, McMaster University, Canada
17.5 million serology tests ordered by UK government have all been proven ineffective
Spanish government recalled 58,000 serology testing kits from China after discovering accuracy rate was 30%
More than 4,000 samples gone untested in Telluride, Colorado, US after New York-based lab closed due to COVID-19 infections
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1 Needs strong testing capacity to determine Covid-19 positives3User data privacy concerns, especially in
EU, US, and UK, may prevent approval
2 Low adoption rates in voluntary contact tracing schemes could limit efficacy
5 Tools capable of amplifying false positives or negatives
6 Technology could come too late
Source: L Kelion, “Apple and Google team up to contact trace Covid-19”, BBC, April 10, 2020; J Taylor, “Australia’s coronavirus contact tracing app”, Guardian, April 16, 2020; R Cohen, “1.5 million Israelis using voluntary coronavirus monitoring app”, Reuters, April 1, 2020.
But apps unlikely to be a ‘silver bullet’ for COVID-19Contact tracing tech a promising way of easing restrictions
Advisory Board interviews and analysis.
Uses anonymised Bluetooth smartphone infrastructure to alert user if they have been within close proximity (~2 m) of an infected person
How contact tracing tools work
Significant limitations may hinder success
4 Many stakeholders in the public health ecosystem need to agree on common approach
Contact tracing technology gaining traction
Apple and Google undertake massive contact tracing project (3.5bn devices); hope to integrate with existing national tools
Australian government developing voluntary contact tracing tool based on Singapore’s Trace Together app
1.5M Israelis use the government’s HaMagen app; Germany, UK, and Chile are basing their technology on the software
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Three patient ‘crunches’ moving forward
Advisory Board interviews and analysis.
First step is solidifying your COVID pathways and staffing arrangements
Challenge: Surge in delayed procedures while productivity dips due to sanitation re-quirements and scarce PPE; must treat all patients as COVID-positive upon enteringImperatives: • Have a plan for identifying and
recapturing delayed/cancelled cases• Minimise any unnecessary variation or
inefficiencies (for all case types) to preserve resources
• Prioritise provider wellbeing—accommodating pent-up demand will take a healthy, engaged workforce—right when everyone needs a vacation
Immediate: COVID crunch
Challenge: Sudden influx of COVID patients requiring isolation and new pathways; some systems on the financial hook without elective revenue to offset lossesImperatives: • Activate alternative sites of care e.g.,
virtual channels, outlying facilities• Configure to accept as much of COVID-
19 demand surge as possible • Minimise any unnecessary complications
or inefficiencies (for all conditions) to preserve resources
Imminent: Elective crunch
Looming: Complexity crunch
Challenge: Chronic patients flood system after foregoing care for months, rise in latent disease due to delayed diagnostics and COVID complications; must treat all patients as COVID-positive upon enteringImperatives (start now): • Shift all scheduled visits to virtual option• Analyse March/April diagnostic and
follow-up visit drop-off compared to years’ past to estimate size, timeline of crunch
• Begin crunch planning with post-acute and primary care partners immediately
• Extend specialty and care management training (virtual is an option) to community providers needing to manage higher-complexity patients post-discharge
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Where your peers are sending their COVID patients
Non-hospital health care facilities Non-health care facilities
Designate off-site screening and treatment centers: Urgent care centers can absorb COVID testing responsibilities or serve as respiratory illness-only clinics
Repurpose hotels, dorms to house patients: Facilities have existing private rooms, bathrooms, laundry, cleaning, and food service capabilities
Build treatment space within convention centers, arenas, stadiums: Existing infrastructure, workforce allows for quick repurposing to large treatment facility
Create testing, treatment sites in large open spaces (e.g., parks, fields, parking lots): Allows hospitals to utilise open space close to existing facilities to streamline patient and staff transfer
Transition specific patients or services to other care sites: Outpatient clinics can absorb specific urgent surgical and medical volumes
Lean on primary care providers for non-urgent issues: GPs can manage ongoing primary care needs via telehealth
Advisory Board interviews and analysis.
To access a COVID-19 checklist to expand capacity, visit advisory.com/covid19
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Direct patients to remote triage and virtual visits first
• Assessment tool identifies patient in need of virtual visit• NP provides in-depth consultation over live video• Hospital has protocol to safely transfer patient without
infecting others
Severe cases
• Assessment tool identifies patients to self-care at home• Telehealth team monitors patient at home using virtual
visits and some form of remote monitoring
Mild cases
• Chatbot prepopulated with FAQs addressingsymptoms, self-isolation, and other common worries
• Most users don’t have to talk to a physician
Worried well
Providence St. Joseph’s COVID-19 chatbot
Chatbots increase clinical capacity to focus on severe cases
Invested heavily in pointing patients to the chatbot, and gave it prominent positioning on Providence website
Preparing to scale up tech capabilities and staffing as number of infected patients increase
Advisory Board interviews and analysis.
Source: Providence St. Joseph Health, Renton, WA.
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15Source: “COVID-19 Hospital Discharge Service Requirement”, NHS England, March 19, 2020.
Support post-acute providers to help drive throughputUK created national discharge strategy to ease concerns
NHS England’s hospital discharge model
1
2
NHS centrally funds the cost of new or extended out-of-hospital health and social care support packages
Create a Discharge to Assess model based on four pathways:
Eliminate transfer barriers – namely funding and pathway ambiguity – to efficiently discharge from acute settingGoal
How they’re doing it
Advisory Board interviews and analysis.
3 Delineate clear responsibilities across the health and social care system:• Acute hospitals will be responsible for
leading on the discharge of all patients on pathway 0, ensuring that 50% of patients who need minimal support can leave the hospital on time
• Community providers will lead on pathways 1-3 as they will play a key rolein providing the required rehabilitation support at home
Pathway 0: 50% of people simply discharged home, no input from health system
Pathway 1: 45% of people need health and social care rehab support at home
Pathway 3: 1% of people cannot be discharged, remain in palliative care
Pathway 2: 4% of people receive rehabilitation in bedded setting
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1. Post-traumatic stress disorder.Source: E Cheung, “Some recovered patients may have reduced lung function”, South China Morning Post, March 13, 2020; A Murray, et al., “We need a Nightingale model for rehab after covid-19”, HSJ, April 8, 2020.
Half of recovering COVID patients will require some form of ongoing careDischarge strategy must consider long-term rehabilitation
Advisory Board interviews and analysis.
1Successfully discharge
Support post-acute recovery with staff and resources in order to:• Improve long-term outcomes for survivors• Reduce risk of hospital readmission• Maintain maximum capacity at acute hospitals
2Support rehabilitation
Transfer COVID-19 patients out of the hospital
Steps for managing COVID-19 survivors
30-80% of ICU survivors experience cognitive impairment
25-80% of ICU survivors develop a new physical impairment
20-30% of COVID survivors have re-duced lung function
ICU survivors may experience PTSD1, anxiety, depression
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1. With at least one year of graduate medical education. Source: 76,000 Healthcare Workers Have Volunteered to Help NY Hospitals Fight Coronavirus, Forbes, March 29, 2020.
NY deploys variety of strategies to increase clinician supply
Advisory Board interviews and analysis.
Sampling of strategies deployed by New York to increase clinician supply
Over 70,000 medical volunteers answered the call
Asking retired medical professionals to volunteer
Relaxing licensure requirements for out-of-state clinicians
Allowing NPs to practice without physician oversight
Allowing students to volunteer without a clinical affiliation agreements
Removing limits on working hours for physicians
Allowing foreign graduates1 to provide care without licenses
30,000+ Registered
Nurses
8,000+Physicians
6,000+Licensed
Practical Nurses
3,000+Nurse
Practitioners
1,000+Physician Assistants
12,000+ Mental health professionals
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Source: NHS Employers, “Enabling staff movement,” 8 April 2020; Advisory Board, “4 Ways Allegheny Health Network is flexing its nurse staffing for the Covid-19 surge,” 7 April 2020.
A flexible staffing approach is your new baselineSystems, governments use creative strategies to redeploy staff
Advisory Board interviews and analysis.
Allegheny Health Network’s nurse extender strategy NHS England lowering barriers to shift staff
Redeployed nurses work as ‘nurse extenders’, with one nurse extender for every two ICU nurses and one extender for every three nurses in all other units
Digital ‘staff passports’ will create an embedded licence to attend agreement and store verified credentials on health care workers’ smartphones
Fast-tracking initiative that makes it easier for health care workers to move between organisations to meet COVID-19 need
OR and ambulatory site nurses redeployed toacute care
Responsibilities include communicating with patients’ families, relieving nurses for breaks, and assisting with the donning and doffing of PPE
Goal of passport program is to help NHS organisations move staff safely, quickly, and ‘without unnecessary bureaucracy’
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Quarantined patients are kept away from mainbuilding in a field hospital, wherecare is delivered through a robotic telemedicine cart
Protect providers across facilities with virtual solutions
Doctors monitor patients from dashboards in the main hospital building, protecting doctors from additional exposure to infection
Doctors decide if the patient can be treated at home with RPM and virtual visits or if they need to be admitted and treated in quarantine
Remote monitoring• Sensor patches measures
heart rate and motion• Tyto Care devices
measure blood pressure
Communication• TV for video conferencing• Phones• Emergency buttons• Security cameras
Sheba Medical Center’s telehealth programme
RPM1 and robotics allow providers to deliver necessary care at a distance
Source: Sheba Medical Center, Ramat Gan, Israel.
Advisory Board interviews and analysis.
1. Remote patient monitoring.
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Three patient ‘crunches’ moving forward
Advisory Board interviews and analysis.
Assessing potential cases after COVID surge passes
Challenge: Surge in delayed procedures while productivity dips due to sanitation re-quirements and scarce PPE; must treat all patients as COVID-positive upon enteringImperatives: • Have a plan for identifying and
recapturing delayed/cancelled cases• Minimise any unnecessary variation or
inefficiencies (for all case types) to preserve resources
• Prioritise provider wellbeing—accommodating pent-up demand will take a healthy, engaged workforce—right when everyone needs a vacation
Immediate: COVID crunch
Challenge: Sudden influx of COVID patients requiring isolation and new pathways; some systems on the financial hook without elective revenue to offset lossesImperatives: • Activate alternative sites of care e.g.,
virtual channels, outlying facilities• Configure to accept as much of COVID-
19 demand surge as possible • Minimise any unnecessary complications
or inefficiencies (for all conditions) to preserve resources
Imminent: Elective crunch
Looming: Complexity crunch
Challenge: Chronic patients flood system after foregoing care for months, rise in latent disease due to delayed diagnostics and COVID complications; must treat all patients as COVID-positive upon enteringImperatives (start now): • Shift all scheduled visits to virtual option• Analyse March/April diagnostic and
follow-up visit drop-off compared to years’ past to estimate size, timeline of crunch
• Begin crunch planning with post-acute and primary care partners immediately
• Extend specialty and care management training (virtual is an option) to community providers needing to manage higher-complexity patients post-discharge
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1. Includes type 1-3 A&E attendances, type 1-4, and other emergency admissions.2. Percutaneous coronary intervention.3. ST-Elevation Myocardial Infarction.
Source: NHS England, “A&E Attendances and Emergency Admissions: Time series”, March 20, 2020; Rodriguez-Leor, et al., “Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España”, Revista Española de Cardiología, April 2, 2020; J Bakker, “Lives at risk due to 50% drop in heart attack A&E attendance”, British Heart Foundation, April 9, 2020; D Campbell, et al., “Warning as UK coronavirus outbreak leads to sharp rise in deaths at home”, Guardian, April 16, 2020.
Social distancing and fear of infection keeping people away from health care COVID-19 already impacting non-elective utilisation
NHS England total A&E attendances and emergency admissions Q4-Q1, 2015-201
1,247
429644
258
PCI STEMI
February 24 - March 1 March 16 - March 22
Number of cardiology interventions in Spain before and during COVID-19 pandemic
Advisory Board interviews and analysis.
48%
Oct Nov Dec Jan Feb Mar
2015/16 2016/17 2017/18 2018/19 2019/20
2.3M2.2M
1.6M
2.1M
Covid-19
DATA SPOTLIGHT
Additional cardiac arrest deaths per day in London since beginning of April85
71% of cardiologists believe patients are afraid to visit the hospital due to Covid-19
2 3
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1. Based on study of 500 Italian cancer patients.2. Treatments included chemotherapy and radiotherapy.
Longer term, expect a surge in patient complexity
Advisory Board interviews and analysis.
Conditions that could require higher intensity care if people delay medical attention
Acute myocardial infarction Stroke Cancer Fractures and other
orthopaedic trauma
40%
Breast and pancreatic cancer treatment in Italy1,2
50-75% 24%
New pathology appointments made in Australia
March 15 April 15
Bypass and stent operations in Canada
Decreases in routine checks and procedures across regions
March 15 Present March April
Source: L Tondo, “Life ‘hanging by a thread’ for Italian cancer patients”, Guardian, April 7, 2020; M Cunningham, “Critically ill patients risk their lives to avoid hospital visits”, The Sunday Morning Herald, April 13, 2020; T Blackwell, “Surgery for cancer patients and others cancelled as hospitals brace for possible COVID-19 wave”, National Post, March 2018, 2020.
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Sources: Abelson R, “Doctors and Patients Turn to Telemedicine in the Coronavirus Outbreak,” The New York Times, March 2020; CipherHealth, “Using Proactive Outreach with Automated Coronavirus Screening to Minimize Community Risk of Exposure,” March 2020.
Use telehealth as default for all scheduled, routine visitsSystems getting ahead of complexity crunch with telehealth
Intermountain Healthcare• Expanding telehealth to home
health care for patients with chronic illnesses
• Patients take blood pressure or blood sugar readings at home and conduct virtual visits with a nurse
UCSF Medical Center2
• Automated telephone outreach system screens patients with upcoming appointments for COVID-19 symptoms
• Potentially-infected patients are connected with a virtual care team for triage instead of in-person visit
NYU Langone Health1
• Patients with minor medical conditions directed to a virtual urgent care platform
• Patients with existing medical conditions asked to conduct visits virtually
• Self-quarantined providers able to treat patients virtually
Three approaches to ramp up telehealth capabilities
1. New York University Langone Health.2. University of California, San Francisco Medical Center.
Advisory Board interviews and analysis.
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1. National Health Service, England.Source: J Illman, “Coronavirus response could create ‘very serious unintended consequences’”, HSJ, 5 April 2020; S Marsh, “UK Government campaign will urge seriously ill not to avoid hospitals,” The Guardian, 13 April 2020.
NHS already seeking to mitigate unintended consequences
Advisory Board interviews and analysis.
NHS England identifying at-risk groups and building intervention plans before complexity surge
Data shows significant drops in ED attendances, indicating people with serious health problems are avoiding care
NHSE1 established group to identify non-COVID-19 patients at risk of significant harm or death due to missed care
Goal to understand the scale of the problem, identify key patient groups, and plan appropriate interventions
The government is now planning a major public awareness campaign to stress that the NHS is still there for those who need it. The advertising agency Saatchi & Saatchi is understood to be working on the campaign without payment and it is expected to be launched in the next few weeks.”
The Guardian
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Many providers will be constrained in ability to identify, serve all backlogged casesHow big is the pent up demand?
Advisory Board interviews and analysis.
When do we reopen this service?
How many patients leave the queue?
What is our post-COVID capacity for this service?
How is post-COVID demand for this service different?
• Safety• Legal restrictions• PR concerns• Financial pressure
Longer shutdowns mean a larger backlog of unserved demand and more latent disease left to uncover
For any service, identifying and serving deferred demand depends on a four-part analysis:
More movement to other providers makes it easier to clear backlog, but means clinical history/data becomes split across geography
Productivity will be far lower than pre-COVID levels due to increased hygiene and PPE protocols, meaning staff pay will decrease per case
Lower new demand would make it easier to clear backlog, but difficult or impossible to sustain pre-COVID volumes
• Self-resolving issues• Care plan changes• Patients visiting other
providers that reopen earlier
• OR capacity• Staff, especially
specialised surgeons• PPE supply• New sanitation protocols
• Lingering fears of visiting health care facilities (-)
• Economic stress (-)• Poorly managed conditions (+)• Durable shifts in modality (e.g.,
telemedicine) (+/-)
Implications
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Your top resources for COVID-19 readiness
Advisory Board interviews and analysis.
To access the top COVID-19 resources, visit advisory.com/covid-19
WHO Guidelines Compiles evidence-based information on hospital and personnel preparedness, COVID-19 infection control recommendations, clinical guidelines, and case trackers
Coronavirus scenario planning Explores ten situations hospital leaders should prepare for and helps hospital leadership teams pressure test the comprehensiveness of their preparedness planning efforts and check for blind spots
Managing clinical capacity Examines best practices for creating flexible nursing capacity, maximising hospital throughput in times of high demand, increasing access channels, deploying telehealth capabilities, and engaging clinicians as they deal with intense workloads
How COVID-19 is transforming telehealth—now and in the future Explores how telehealth is being deployed against COVID-19 and essential next steps for telehealth implementation
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