ON PERFORMANCE IMPROVEMENT

OF HEALTH SERVICES
 BENCHBOOK

Lays
Lays out
out basic
basic concepts
concepts on
on the
the value
value
of
of quality
quality assurance
assurance in
in health
health care.
care.
 GOALS:

 Serve
 Serve to
to attain
attain quality
quality
performance.
performance.
 To
 To meet
meet standards
standards..
 AIMS
 To
To show
show PhilHealth
PhilHealth providers
providers that
that itit can
can
serve
serve Filipinos
Filipinos with
with high
high quality
quality care.
care.
 A
A systematic
systematic overview
overview ofof the
the accreditation
accreditation
process,
process, policies
policies && standards,
standards, in in relation
relation
with
with its
its mission
mission as
as an
an insurance
insurance company.
company.
 Envisioned
Envisioned to to serve
serve as
as aa yardstick
yardstick for for
measuring
measuring & & assessing
assessing the
the quality
quality of
of care
care
rendered
rendered by by PhilHealth
PhilHealth & & its
its accredited
accredited
health
health care
care providers
providers && professionals.
professionals.
 Part I
 PhilHealth
PhilHealth && the
the Health
Health Sector
Sector Reform
Reform
 The
The PhilHealth
PhilHealth Quality
Quality Assurance
Assurance
 The
The Focus
Focus of
of the
the Quality
Quality Assurance
Assurance
Framework
Framework
 Implementing
Implementing the the New
New Quality
Quality Assurance
Assurance
Framework
Framework
 What
What is
is Quality
Quality ofof Care?
Care?
 Why
Why is
is Quality
Quality Care
Care Important?
Important?
 Where
Where Quality
Quality ofof Care
Care Starts
Starts
 Assessing
Assessing Quality
Quality of of Care
Care
 Improving
Improving Quality
Quality of of Health
Health Care
Care
 PhilHealth && the
 PhilHealth the Health
Health Sector
Sector Reform
Reform
Agenda
Agenda


 RA
RA6111-Philippine
6111-PhilippineMedical
MedicalCare
CarePlan
Plan

 RA
RA7875-National
7875-NationalHealth
HealthInsurance
InsuranceAct
Act
 The New Philhealth Quality Assurance Framework
 The New Philhealth Quality Assurance Framework
 The Focus of the Quality Assurance Framework
 The Focus of the Quality Assurance Framework

 Accountability framework
 Accountability framework
>Current quality assurance framework
>Current quality assurance framework
>New Quality assurance framework
>New Quality assurance framework
 Implementing the New Quality Assurance Framework
 Implementing the New Quality Assurance Framework

 Implementation of QA framework
 Implementation of QA framework
>Accreditation
>Accreditation
>Clinical Practice Guidelines
>Clinical Practice Guidelines
>Performance Measurements
>Performance Measurements

 WHAT
WHATIS ISQUALITY
QUALITYOF
OFCARE?
CARE?
 PATIENTS
PATIENTS
 PROVIDERS
PROVIDERS
 PHILHEALTH
PHILHEALTH
QUALITY
QUALITYOF OFCARE
CARE
 SAFE
SAFE
 EFFICIENT
EFFICIENT
 EFFECTIVE
EFFECTIVE
 APPROPRIATE
APPROPRIATE
 ACCESIBLE
ACCESIBLE
 PATIENT
PATIENTCENTERED
CENTERED

 Why
Why is
is quality
quality of
of Care
Care Important?
Important?

 “First
“First do
do no
no harm”
harm”
 Use
Use resources
resources
 Professionalism
Professionalism
 Survival
Survival

 Where
WhereQuality
QualityofofHealth
HealthCare
Carestarts
starts
>patient
>patient
>provider
>provider


 Selection
Selection

 Effective,
Effective,efficient
efficient
 Assessing Quality of Health Care
 Assessing Quality of Health Care

Evaluation
Evaluationof:
of:
>structural
>structural
>process
>process
>outcome
>outcome
 Improving Quality of Health Care
 Improving Quality of Health Care
>manufacturing
>manufacturing
>Health Service delivery
>Health Service delivery

 TQM-Total
TQM-TotalQuality
QualityMovement
Movement

 QI
QI––Quality
QualityImprovement
Improvement

 QA
QA––Quality
QualityAssurance
Assurance

 QC_
QC_Quality
QualityControl
Control
Part
Part II
II
 Benchmark
Benchmark of
of performance
performance improvement.
improvement.

1.1. Patient
Patient Rights
Rights && Organizational
Organizational Ethics
Ethics
2.2. Patient
Patient Care
Care
3.3. Leadership
Leadership & & Management
Management
4.4. Human
Human Resource
Resource Management
Management
5.5. Information
Information Management
Management
6.6. Safe
Safe Practice
Practice &
& Environment
Environment
7.7. Performance
Performance Improvement
Improvement
Part
Part III
III
Implementing
Implementing aa Performance
Performance
Improvement
Improvement Program
Program
 Rationale
Rationale&&Steps
Stepsfor
forPerformance
Performance
Improvement
Improvement
 TQM Program Implementation Steps
TQM Program Implementation Steps
 The Documentation-Evaluation-Action Triad
The Documentation-Evaluation-Action Triad
 The Plan-Do-Check-Act (PDCA) cycle
The Plan-Do-Check-Act (PDCA) cycle
 Quality Improvement Tools
Quality Improvement Tools
 Quality Circle & Quality Teams
Quality Circle & Quality Teams
 Quality Improvement Activities
Quality Improvement Activities
 Rationale
Rationale &
& Steps
Steps for
for Performance
Performance
Improvement
Improvement

>Documentation
>Documentation
>Action
>Action
>Evaluation
>Evaluation

 TQM
TQM
>Management
>ManagementAwareness
Awareness
>Mobilization
>Mobilization
>Launching
>LaunchingofofPerformance
PerformanceImprovement
ImprovementActivities
Activities

 DOCUMENTATION
DOCUMENTATION –EVALUATION-ACTION
–EVALUATION-ACTION
TRIAD
TRIAD
>DOUMENTATION
>DOUMENTATION
>EVALUATION
>EVALUATION
>ACTION
>ACTION


 PLAN-DO-CHECK-ACT
PLAN-DO-CHECK-ACT
>PLAN
>PLAN
>ACT
>ACT
>DO
>DO
>ACT
>ACT
 Quality Circle Teams & Quality Teams
>composed of a quality team ;
>members of the clinical team
>accounting & billing section
>dietary
>rehabilitation
>housekeeping dept.

 Q
Quuaalliittyy IIm
mpprroovveem
meenntt A
Accttiivviittiieess
 CClliinniiccaall PPrraaccttiiccee G
Guuiiddeelliinneess

 CClliinniiccaall PPaatthhwwaayyss G
Guuiiddeelliinneess
>>ppaattiieenntt oouuttccoom meess
>>ttiim
meelliinnee
>>ccoollllaabboorraattiioonn
>>ccoommpprreehheennssiivvee aassppeeccttss ooff ccaarree
 QUALITY STANDARDS FOR HEALTH CARE

PERFORMANCE IMPROVEMENT PATIENT RIGHTS AND

ORGANIZATIONAL ETHICS

PATIENT CARE

SAFE PRACTICE AND ENVIRONMENT

INFORMATION MANAGEMENT LEADERSHIP AND MANAGEMENT

HUMAN RESOURCE MANAGEMENT

 PATIENT RIGHTS AND
ORGANIZATIONAL ETHICS
RESPECT AND SUPPORT FOR PATIENTS’
RIGHTS AND RESPONSIBILITIES

STANDAR OPPORTUNITIES FOR PATIENTS’

INVOLVEMENT IN CARE PROVISION
DS
CONFIDENTIALITY AND SECURITY OF
PATIENTS’ INFORMATION AND
COMMUNICATION

FEEDBACK TO PATIENTS

STAFF CODE OF ETHICS

RESOLUTION OF ETHICAL ISSUES

 PATIENT RIGHTS AND
ORGANIZATIONAL ETHICS

GOAL:
TO
TOIMPROVE
IMPROVEPATIENTS’
PATIENTS’
OUTCOMES
OUTCOMESBYBYRESPECTING
RESPECTING
PATIENTS’
PATIENTS’RIGHTS
RIGHTSAND
AND
ETHICALLY
ETHICALLYRELATING
RELATINGWITHWITH
PATIENTS
PATIENTSAND
ANDOTHER
OTHER
ORGANIZATIONS
ORGANIZATIONS. .
PATIENT CARE
ACCESS STANDARDS
INFORMATION
INFORMATIONABOUT
ABOUT
SERVICES
SERVICES

ACCESS
ACCESSTO
TOSERVICES
SERVICES

GOAL:

THE ORGANIZATION IS
THE ORGANIZATION IS
ACCESSIBLE TO THE
ACCESSIBLE TO THE
COMMUNITY THAT IT
COMMUNITY THAT IT
AIMS TO SERVE
AIMS TO SERVE
 PATIENT CARE
GOAL:
ENTRY STANDARDS
THE ENTRY
PROMPT THE ENTRY
PROMPTAND
ANDTIMELY
TIMELY PROCESSES MEET
ATTENTION PROCESSES MEET
ATTENTION PATIENT NEEDS
PATIENT NEEDS
AND ARE
EFFICIENT AND ARE
EFFICIENTTRIAGING
TRIAGING SUPPORTED BY
SUPPORTED BY
EEFECTIVE
EEFECTIVE
UNIQUE
UNIQUEPATIENT
PATIENT SYSTEMS AND A
SYSTEMS AND A
IDENTIFICATION
IDENTIFICATION SUITABLE
SUITABLE
ENVIRONMENT
ENVIRONMENT
INFORMED
INFORMEDCONSENT
CONSENT

PLANNING
PLANNINGFOR
FORDISCHARGE
DISCHARGE
AND
ANDCONTINUING
CONTINUINGCARE
CARE
 PATIENT CARE
COORDINATED
COORDINATED
PHYSICAL,
PHYSICAL, ASSESSMENT
ASSESSMENTBY
BY
PSYCHOLOGICAL
PSYCHOLOGICAL PROFESSIONALS
PROFESSIONALS REGULAR
REGULAR
,, ASSESSMENTS
ASSESSMENTS
SOCIAL
SOCIAL
ASSESSMENT
ASSESSMENT
ASSESSMENT STANDARDS
PROPER
PROPER
DOCUMENTATIO SPECIAL
SPECIALNEEDS
NEEDS
DOCUMENTATIO
N ASSESSMENT
ASSESSMENT
NOF
OF
ASSESSMENTS
ASSESSMENTS APPROPRIATE
APPROPRIATE
DIAGNOSTICS
DIAGNOSTICS
PATIENT CARE
GOAL:

COMPREHENSIVE
COMPREHENSIVE
ASSESSMENT OF
ASSESSMENT OF
EVERY PATIENT
EVERY PATIENT
ENABLES THE
ENABLES THE
PLANNING AND
PLANNING AND
DELIVERY OF PATIENT
DELIVERY OF PATIENT
CAREc
CAREc
 PATIENT CARE
CARE PLANNING STANDARDS
RELEVANT
RELEVANTTO
TOPATIENT
PATIENTNEEDS
NEEDS

EVIDENCE-
EVIDENCE-BASED
BASEDCARE
CAREPLAN
PLAN

CLEAR
CLEARAND
ANDACCESSIBLE
ACCESSIBLE
INFORMATION
INFORMATIONON
ONCARE
CARE

THE HEALTH CARE TEAM DEVELOPS

THE HEALTH CARE TEAM DEVELOPS
IN PARTNERSHIP WITH THE PATIENTS
GOAL: IN PARTNERSHIP WITH THE PATIENTS
A COORDINATED PLAN OF CARE
A COORDINATED PLAN OF CARE
WITH GOALS
WITH GOALS
 PATIENT CARE
IMPLEMENTATION OF CARE STANDARDS
TIMELY,
TIMELY,SAFE,
SAFE,APPROPRIATE
APPROPRIATE
AND
ANDCOORDINATED
COORDINATEDCARE
CARE
DELIVERY
DELIVERY
RESPECT
RESPECTFOR
FORPATIENTS’
PATIENTS’NEEDS
NEEDS
AND
ANDRIGHTS
RIGHTS
COORDINATED
COORDINATEDCARE
CAREDELIVERY
DELIVERY
AMONG
AMONGPROFESSIONAL
PROFESSIONAL

PATIENT
PATIENTEDUCATION
EDUCATION

STANDARDIZED
STANDARDIZEDDRUG
DRUG
ADMINISTRATION
ADMINISTRATION
STANDARDIZED
STANDARDIZEDTREATMENT
TREATMENT
PROCEDURES
PROCEDURES
APPROPRIATE
APPROPRIATECARE
CAREFOR
FOR
PATIENTS
PATIENTSWITH
WITHSPECIAL
SPECIALNEEDS
NEEDS
 PATIENT CARE
CARE IS DELIVERED TO ENSURE
GOAL: CARE IS DELIVERED TO ENSURE
THE BEST POSSIBLE OUTCOMES
THE BEST POSSIBLE OUTCOMES
FOR THE PATIENT
FOR THE PATIENT
 PATIENT CARE
EVALUATION OF CARE STANDARDS
ANALYSIS
ANALYSISOF
OFPROCESS
PROCESSAND
AND
OUTCOMES
OUTCOMESDATA
DATA

ACTIONS
ACTIONSFOR
FORIMPROVEMENT
IMPROVEMENT
ACTIVITIES
ACTIVITIES

GOAL:
THE HEALTH CARE TEAM
THE HEALTH CARE TEAM
ROUTINELY AND SYSTEMATICALLY
ROUTINELY AND SYSTEMATICALLY
EVALUATES AND IMPROVES THE
EVALUATES AND IMPROVES THE
EFFECTIVENESS AND EFFICIENTCY
EFFECTIVENESS AND EFFICIENTCY
OF CARE DELIVERED TO PATIENTS
OF CARE DELIVERED TO PATIENTS
 PATIENT CARE
CARE PLANNING STANDARDS
PATIENT
PATIENTACCESS
ACCESSTO
TO
DISCHARGE
DISCHARGEPLAN
PLAN COMMUNITY
COMMUNITYHEALTH
HEALTH
SERVICES
SERVICES
PATIENT
PATIENT
CONTINUING
CONTINUING UNDERSTANDING
UNDERSTANDINGOF OF
MANAGEMENT
MANAGEMENTPLAN
PLAN DISCHARGE
DISCHARGEPLAN
PLAN
GOAL:
CARE IS COORDINATED
CARE IS COORDINATED
BETWEEN THE
BETWEEN THE
ORGANIZATION AND
ORGANIZATION AND
OTHER HEALTH CARE
OTHER HEALTH CARE
PROVIDERS IN THE
PROVIDERS IN THE
COMMUNITY TO ENSURE
COMMUNITY TO ENSURE
THAT THE NEEDS OF THE
THAT THE NEEDS OF THE
PATIENT ARE
PATIENT ARE
CONTINUOUSLY MET
CONTINUOUSLY MET
LEADERSHIP AND MANAGEMENT
THE MANAGEMENT
TEAM STANDARDS GOAL:
LEADERSHIP
LEADERSHIP
THE ORGANIZATION IS
EFFECTIVE
EFFECTIVEWORKING
WORKING EFFECTIVELY AND EFFICIENTLY
RELATIONSHIPS
RELATIONSHIPS GOVERNED AND MANAGED
COMMITTEE ACCORDING TO ITS VALUES
COMMITTEE AND GOALS TO ENSURE THAT
MEETINGS
MEETINGS CARE PRODUCES THE DESIRE
MANAGEMENT
MANAGEMENT HEALTH OUTCOMES, AND IS
PERFORMANCE
PERFORMANCE RESPONSIVE TO PATIENTS’
ASSESSMENT
ASSESSMENT AND COMMUNITY NEEDS
POLICIES
POLICIESAND
AND
PROCEDURES
PROCEDURESFORFOR
OPERATIONS
OPERATIONS
LEADERSHIP AND MANAGEMENT
EXTERNAL SERVICES STANDARDS
CONTRACTS
CONTRACTS

GOAL:
THE ORGANIZATION
ENSURES THAT SERVICES
PROVIDED BY EXTERNAL
CONTRACTORS MEET
APPROPRIATE
STANDARDS
HUMAN RESOURCE MANAGEMENT
HUMAN RESOURCES PLANNING STANDARDS
HR
HRNEEDS
NEEDSASSESSMENT
ASSESSMENT

WORKLOAD
WORKLOAD
MONITORING
MONITORING

GOAL:
THE ORGANIZATION
THE ORGANIZATION
PROVIDES THE RIGHT
PROVIDES THE RIGHT
NUMBER AND MIX OF
NUMBER AND MIX OF
COMPETENT STAFF TO
COMPETENT STAFF TO
MEET THE NEEDS OF ITS
MEET THE NEEDS OF ITS
INTERNAL AND EXTERNAL
INTERNAL AND EXTERNAL
CUSTOMERS AND TO
CUSTOMERS AND TO
ACHIEVE ITS GOAL
ACHIEVE ITS GOAL
HUMAN RESOURCE MANAGEMENT
STAFF PROCEDURES
PROCEDURES
RECRUITMENT,
SELECTION, JOB
JOBDESCRIPTIONS
DESCRIPTIONS
APPOINMENT AND STAFF
STAFF
RESPONSIBILITIES ACCOUNTABILITIES
ACCOUNTABILITIES
STANDARDS SERVICE
SERVICEPROVISION
PROVISIONBY
BY
APPROPRIATE
APPROPRIATESTAFF
STAFF
GOAL:
RECRUITMENT, SELECTION AND
RECRUITMENT, SELECTION AND
APPOINTMENT OF STAFF COMPLY
APPOINTMENT OF STAFF COMPLY
WITH STATUTORY REQUIREMENTS
WITH STATUTORY REQUIREMENTS
AND ARE CONSISTENT WITH THE
AND ARE CONSISTENT WITH THE
ORGANIZATION’S HUMAN
ORGANIZATION’S HUMAN
RESOURCE POLICIES
RESOURCE POLICIES
HUMAN RESOURCE MANAGEMENT
STAFF TRAINING AND DEVELOPMENT
STANDARDS ORIENTATION,
ORIENTATION,
TRAINING
TRAININGAND
AND
DEVELOPMENT
DEVELOPMENT
PROGRAMS
PROGRAMS
SUPERVISION
SUPERVISION

GOAL:
A COMPREHENSIVE
A COMPREHENSIVE
PROGRAM OF STAFF
PROGRAM OF STAFF
TRAINING AND
TRAINING AND
DEVELOPMENT MEETS
DEVELOPMENT MEETS
INDIVIDUAL AND
INDIVIDUAL AND
ORGANIZATIONAL
ORGANIZATIONAL
NEEDS
NEEDS
INFORMATION MANAGEMENT
DATA COLLECTION, AGGREGATION AND
USE STANDARDS
TIMELY AND
DETAILED
EFFICIENT DATA
MEDICAL CHARTS
COLLECTION
CODING AND
STANDARDIZED
INDEXING OF
INFORMATION
DATA

GOAL: COLLECTION
COLLECTIONAND
AND
AGGREGATION
AGGREGATIONOF OFDATA
DATAARE
ARE
DONE
DONEFOR
FORPATIENT
PATIENTCARE,
CARE,
MANAGEMENT
MANAGEMENTOF OFSERVICES,
SERVICES,
EDUCATION
EDUCATIONAND
ANDRESEARCH
RESEARCH
INFORMATION MANAGEMENT
RECORDS MANAGEMENT STANDARDS
ACCESIBLE
RECORDS

GOAL:
INTEGRITY,
INTEGRITY,SAFETY,
SAFETY,
ACCESS
ACCESSANDANDSECURITY
SECURITY
OF
OFRECORDS
RECORDSARE
ARE
MAINTAINED
MAINTAINEDAND
AND
STATUTORY
STATUTORY
REQUIREMENTS
REQUIREMENTSARE AREMET
MET
SAFE PRACTICE AND ENVIRONMENT
PATIENT AND STAFF SAFETY STANDARDS
PLAN OF SAFE AND
ROUTINE EVALUATION
EFFECTIVE
OF ENVIRONMENT OF
ENVIRONMENT OF
CARE
CAREPROVISION OF SAFE AND
EFFECTIVE ENVIRONMENT
OF CARE

GOAL:
PATIENTS,
PATIENTS,STAFF
STAFFAND
AND
OTHER
OTHERINDIVIDUALS
INDIVIDUALS
WITHIN
WITHINTHE
THE
ORGANIZATION
ORGANIZATIONARE ARE
PROVIDED
PROVIDEDAASAFE,
SAFE,
FUNCTIONAL
FUNCTIONALANDAND
EFFECTIVE
EFFECTIVE
ENVIRONMENT
ENVIRONMENTOF OFCARE
CARE
SAFE PRACTICE AND ENVIRONMENT
MAINTENANCE OF THE ENVIRONMENT OF
CARE STANDARDS
EMERGENCY LIGHT, POWER MAINTENANCE OF
SUPPLY WATER AND EQUIPMENT BY QUALIFIED
VENTILATION PERSONNEL
REGULAR MAINTENANCE CURRENT INFORMATION
OF FACILITIES AND ON PRODUCTS ARE
EQUIPMENT AVAILABLE

GOAL:
AACOMPREHENSIVE
COMPREHENSIVE
MAINTENANCE
MAINTENANCE
PROGRAM
PROGRAMENSURES
ENSURES
AACLEAN
CLEANAND
ANDSAFE
SAFE
ENVIRONMENT
ENVIRONMENT
SAFE PRACTICE AND ENVIRONMENT
INFECTION CONTROL STANDARDS
INFECTION CONTROL
PROGRAM
RISK REDUCTION OF
NOSOCOMIAL
INFECTION
STANDARDIZED CLEANING
AND STERILIZATION
PROCEDURES
INTERNAL AND EXTERNAL
REPORTING

RISKS
RISKSOFOFACQUISITION
ACQUISITIONAND
AND
TRANSMISSION
TRANSMISSIONOF OFINFECTIONS
INFECTIONSAMONG
GOAL: PATIENTS,
PATIENTS,EMPLOYEES,
EMPLOYEES,PHYSICIANS
AMONG
PHYSICIANSAND
AND
OTHER
OTHERPERSONNEL,
PERSONNEL,VISITORS
VISITORSAND
AND
TRAINEES
TRAINEESARE
AREIDENTIFIED
IDENTIFIEDAND
ANDREDUCED
REDUCED
SAFE PRACTICE AND ENVIRONMENT
EQUIPMENT AND SUPPLIES STANDARDS
PLANNING AND
ACQUISITION OF
EQUIPMENT AND SUPPLIES
SPECIALIZED EQUIPMENT
OPERATED BY QUALIFIED
STAFF
SAFE REUSE GUIDELINES

GOAL:
THE
THEPROVISION
PROVISIONOFOF
EQUIPMENT
EQUIPMENTAND
ANDSUPPLIES
SUPPLIES
SUPPORTS
SUPPORTSTHE
THE
ORGANIZATION’S
ORGANIZATION’SROLE
ROLE
SAFE PRACTICE AND ENVIRONMENT
ENERGY AND WASTE MANAGEMENT
STANDARDS
STANDARDIZED WASTE IMPLEMENTING OF A
HANDLING AND DISPOSAL WASTE DISPOSAL
PROGRAM PROGRAM

GOAL:
THE
THEORGANIZATION
ORGANIZATION
DEMONSTRATES
DEMONSTRATESITSITS
COMMITMENT
COMMITMENTTO TO
ENVIRONMENTAL
ENVIRONMENTALISSUES
ISSUESBY
BY
CONSIDERING
CONSIDERINGAND
AND
IMPLEMENTING
IMPLEMENTINGSTRATEGIES
STRATEGIESTOTO
ACHIEVE
ACHIEVEENVIRONMENTAL
ENVIRONMENTAL
SUSTAINABILITY
SUSTAINABILITY
 IMPROVING PERFORMANCE

ORGANIZATION CONFIDENTIALITY
WIDE APPROACH STANDARDS OF DATA

COLLABORATION
BETTER SERVICE
IN NEW PROCESS OF
AND CARE
CARE
EVALUATION OF
MANAGEMENT QUALITY
RESPONSIBILITY IMPROVEMENT
PROGRAM
SERVICE UNIT AND
STAFF
RESPONSIBILITY
IMPROVING PERFORMANCE

THE
THEORGANIZATION
ORGANIZATIONCONTINUOUSLY
CONTINUOUSLYAND AND
SYSTEMATICALLY
SYSTEMATICALLYIMPROVES
IMPROVESITSITSPERFOMANCE
GOALBY
BYINVARIABLY
INVARIABLYDOING
DOINGTHE
PERFOMANCE
THERIGHT
RIGHTTHING
THINGTHE
THE
: RIGHT
RIGHTWAY
THE
WAYTHE
THENEEDS
THEFIRST
NEEDSOF
OFITS
FIRSTTIME
TIMEAND
ITSINTERNAL
ANDBY
INTERNALAND
BYMEETING
MEETING
ANDEXTERNAL
EXTERNAL
CLIENTS
CLIENTS