Monday, February 29, 2016

Friday, February 26, 2016

Share your story!!


Every time we hear about a new round of cuts to Registered Nurses, we hear the same line - patients will not be affected. #Nursesknow better. Share your story about the impacts of cuts and underfunding: #OnPoli

LHIN probing why our patient satisfaction ranks near the bottom

Brian Cross, Windsor Star

Martin Girash, chairman of the Local Health Integration Network board, is pictured in this file photo. Dan Janisse / Windsor Star

Share Adjust Comment Print
People here are more dissatisfied with their health care than almost anywhere else in the province, according to new data that so concerns the Erie St. Clair LHIN that staff have been charged to find out why.
“Clearly it’s a symptom, system wise. That problem with patient satisfaction is a symptom of something we have to address,” Martin Girash, the chairman of the Local Health Integration Network board, said Thursday, referring to a recent report on local health indicators and how they compare to provincial targets.
Two indicators — low patient satisfaction and the high proportion of hospital beds taken up by patients (called alternative level of care) who should be somewhere else such as nursing homes — were flagged for further study, according to Girash. He said staff at the LHIN will be “drilling down” into the data to find out why people are less satisfied here than any of the 14 other health regions in the province, with the exception of two regions in Northern Ontario.
He said a similar red flag was hoisted several years ago when the data showed too few stroke patients were getting treated quickly enough so they could be treated with game-changing clot-busting drugs that can minimize or even reverse the damage. The problem was identified, studied and addressed, and the next time the measurements came out the results for stroke were “fantastic,” said Girash.
“It’s a really, really good example of how monitoring the performance indicators, flagging it, finding out what the problem is, what needs to be done, actually makes a difference.”
The data also shows near-the-top results for: receiving home care from the CCAC within the provincial targets; getting CT scans quickly; getting a spot in long-term care quickly; and fewer repeat customers for hospitals and emergencies. Erie St. Clair is in the middle of the pack for: wait times for hip and knee replacements, cancer surgery and MRIs; emergency department length of stays; and quality of primary care. It scores near the bottom for the percentage of hospital beds taken up by ALCs; wait times for cataract surgery; palliative home support; and patient satisfaction.
Pete Crvenkovski, the LHIN’s director of performance, quality and knowledge management, has asked the Health Ministry for more detailed data on patient satisfaction. The numbers are based on asking a sampling of the population: How satisfied are you with health care in your community? On average across the province, about 87 per cent said they were satisfied or very satisfied. The 14 LHINs ranged between about 81 in the North West LHIN (centred in Thunder Bay) and 92 in Toronto. The Erie St. Clair LHIN had an 82 per cent satisfaction rate, third lowest in the province. Crvenkovski said it looks like the Windsor area has a better satisfaction rate (around 84 per cent), than elsewhere in the LHIN, which covers the Sarnia-Chatham-Windsor region.
Girash said while it’s not yet known why people here are less satisfied, he speculates one reason may be the crowded hospital emergency departments where patients are “hanging from the rafters.” Girash, a retired CEO at Windsor Regional Hospital, went to an ED recently. “I saw people in terrible pain, awful pain. They had already been triaged and were sitting in the waiting room, but there were so many people, the volume was tremendous.”

Windsor Regional Hospital CEO David Musyj.
Windsor Regional Hospital CEO David Musyj. Files / Windsor Star
The same report showing patient dissatisfaction also showed that Windsor Regional’s two EDs have length of stay times for serious cases that are well above the province’s target time of eight hours. Its Met ED averages 11.2 hours and its Ouellette ED — the regional trauma centre that takes the most critical cases — averages 14.6 hours.
The data shows that patients who had recently been to an ED were more dissatisfied with their health care than those who hadn’t been to an ED, according to Crvenkovski. Windsor Regional CEO David Musyj said the hospital has work to do in its EDs.
“That is no different than any hospital in the province, emergency departments struggle with patient satisfaction,” he said.
He said the region’s low patient satisfaction scores shouldn’t be blamed on hospitals, since 90 per cent of the health care people receive comes outside hospitals, from doctor’s offices, home care, clinics and other services. Windsor Regional continually measures patient satisfaction and has numbers better than 82 per cent, said Musyj.
In 2015, the satisfaction rate was 94 per cent at its Met campus, though the rate in the ED was 83. At Ouellette, the overall rate was 90 per cent but 80 per cent in the ED.
The lower satisfaction scores in the ED pull down the hospital’s overall scores, Musyj said.
“That’s the difference maker, why we’re not at 100 per cent, so that’s our focus.”
Dr. Amit Bagga,  president of the Essex County Medical Association, said he believes that, given the resources available, people are doing amazing work locally providing health care.
“I genuinely believe from my heart we have some great people in the city,” said Bagga, a nephrologist (kidney specialist), who cites family doctors, specialists, nurse practitioners and nurses for their excellent care. “But I don’t think we can ignore that good healthcare depends on appropriate resources provided by the provincial government.”

Thursday, February 25, 2016

Ontario Provincial Budget Provides Small Improvements for Ontario Hospitals, say Front-Line Registered Nurses

FOR IMMEDIATE RELEASE                                                                          February 25, 2016

Ontario Provincial Budget Provides Small Improvements for Ontario Hospitals, say Front-Line Registered Nurses

TORONTO – The Ontario Nurses' Association (ONA) says that the provincial budget provides a small increase to hospital funding, which we hope will be invested in front-line registered nurses (RNs) for our patients.

"We have been appalled that the government has starved our hospitals of much-needed funding over the past four years and look forward to the new hospital funding improving the quality of care for Ontarians," said ONA President Linda Haslam-Stroud, RN.

Haslam-Stroud says that it is very important for the Minister of Health, Eric Hoskins, to signal hospitals to invest this increased funding wisely. "Our patients deserve no less," she said. We also call on Minister Hoskins to respond to the tens of thousands of Ontarians who have requested a moratorium on RN cuts.

"Each year of hospital underfunding has left hospitals announcing round after round of RN cuts, 462 of them in 2016 alone," she said. "Our patients in long-term care will see increased funding for nursing and personal care. That will assist in addressing the high acuity of our residents. Community care will help build capacity as the system continues to transform. In addition, long-overdue funding for Nurse Practitioners is also included in this budget. Finally, the government has listened to the front-line RNs who have advocated strongly for our patients."

ONA is the union representing 60,000 registered nurses, nurse practitioners, registered practical nurses and allied health professionals, as well as more than 14,000 nursing student affiliates, providing care in hospitals, long-term care facilities, public health, family health teams, community health centres, the community, clinics and industry.  

Windsor nursing program ranked at the top

February 25, 2016 03:12 from Peter Langille

(photo courtesy University of Windsor)

The University of Windsor nursing program received the maximum seven-year term accreditation.
The Canadian Association of Schools of Nursing issued the maximum seven-year term accreditation for the UWindsor educational unit, as well as its collaborative BScN program with Lambton and St. Clair colleges.
Dean Linda Patrick says this is a recognition of the high standard of education the 300 nurse graduates each year are receiving.
She says it is a detailed process with submissions of documents, followed up by a week-long visit in November by an accreditation team.
She says the accreditation recognizes that all the 4 sites have a level of excellence because the all have an educational unit that is evaluated separately from each other.
She says this puts their graduates in good standing for the work world:  "I would have to say that knowing we have the gold standard, or 7 year accreditation, would please an employer knowing the graduate they're going to hire has gone to a very good school with a good program that's received the accreditation"
The Canadian Association of Schools of Nursing is the national accrediting body for nursing education in Canada. It promotes the process as an objective method to assess professional education programs.
Accreditation by the is a testament to the continued quality of the UWindsor BScN program and its faculty, students and graduates according to Patrick.

Wednesday, February 24, 2016

Stop pushing Windsor nurses to Detroit, MPP Gretzky tells health minister

Stop pushing Windsor nurses to Detroit, MPP Gretzky tells health minister

MPP Lisa Gretzky (NDP — Windsor West) told the Ontario Liberal government in question period Wednesday “to stop pushing out Windsor nurses to the U.S.” Windsor Regional Hospital announced layoffs last month. Tyler Brownbridge / Windsor Star
Registered nurses facing layoff from Windsor Regional Hospital are being interviewed for jobs in Michigan one day and hired the next, says MPP Lisa Gretzky, who on Wednesday told the health minister to “stop pushing out Windsor nurses to the U.S.”
The hospital announced the layoffs last month — a total of 166 full-time-equivalent jobs, primarily RNs, offset partially by the hiring of 80 registered practical nurse FTEs to replace 80 RN FTEs.
Windsor Regional says it is being squeezed financially because overall hospital funding in the province has been frozen at $19 billion for five years, and that money is divided up according to a new funding formula that gives more money to hospitals in areas of higher population growth. That means hospitals in areas like Windsor where growth is slow, the funding goes down — a $10-million reduction last year and another $10-million reduction this year.
A total of 169 full- and part-time nurses are being affected by the cuts, according to the Ontario Nurses Association which has launched a petition and letter writing campaign.
In the Ontario legislature Wednesday, Gretzky (NDP — Windsor West) said the nurses facing layoff are resorting to jobs at Michigan hospitals. “These nurses should be working in Ontario hospitals, not being forced by this government’s cuts to leave the country just to find work,” she said in a question period query to Minister Eric Hoskins.
“When will the Liberals stop cutting our hospitals, stop pushing Ontario’s nurses to take jobs in Michigan and start protecting patient care in all our communities?”
Hoskins replied that his ministry had recently provided Windsor Regional with $7 million in additional money to help with its situation, and added that the hospital is one of only a few in the province with all-RN nursing staffs. Most have moved to an RN-RPN mix. (Actually, while Windsor Regional’s Met location is all-RN, its Ouellette location has an RN-RPN mix. The 80 new RPNs being hired will be going to Met to provide it with a similar mix as at Ouellette.) High-seniority RNs make $44 an hour while RPNs make $27.50.
In his reply to Gretzky, Hoskins said: “I think we should leave it to the experts, to the LHIN, to the local leadership, to make sure the mix of nurses and other staff in the hospital truly meets the patients’ needs.”
Sue Sommerdyk, the Ontario Nurses’ Association local president who represents 1,550 RNs at Windsor Regional, said the minister should be ashamed for blaming Windsor Regional for keeping its level of care “higher” than what other hospitals have.
“I really think it’s appalling,” she said. “With all these issues of workload and patient care and all the things we have today, the government should be augmenting the staff, it should be bringing in RPNs to work with the RNs, not cut the RNs.”
Michigan hospitals have also organized job fairs in Windsor to go after nurses cut by Windsor Regional, according to Gretzky.
But Sommerdyk doesn’t view the Detroit hospitals as a great option. Nurses must have written their Michigan exams and be licensed to work there; there are hassles at the border and tunnel tolls to contend with during their daily commute; there are safety concerns working in Detroit; and the wages and working conditions in these non-unionized hospitals vary widely, Sommerdyk said.
“We want our nurses to stay in Ontario,” she said. “They want to stay in Ontario, they want to work where they grew up, they want to be around their family and friends.”

Health Minister says RN layoff not his fault

Health Minister says RN layoff not his fault

February 24, 2016 03:13 from Peter Langille

Ontario's Health Minister is pointing the finger at management at Windsor Regional Hospital for the layoff of 169 Registered Nurses.
Under questioning at Queen's Park from Windsor West MPP Lisa Gretzky, who is the NDP Health Critic, Eric Hoskins says Windsor Regional is one of only a few hospitals in the province who have not used RPNs more.
Gretzky asked the minister if he knew how many Ontario nurses have had to take jobs in the US: "American hospitals like Beaumont Health Systems in Michigan have come to Windsor to hire nurses who have been cut from our hospitals.  RNs are being interviewed one day and are being hired the very next.  These nurses should be working in Ontario's hospitals, not being forced by this government's cuts to leave this country just to find work)
Hoskins says the Windsor Regional layoffs are the result of decisions made by management at the hospital: "Windsor Regional is one of only a handful, only a few hospitals around the province that never made a transition to look at its nursing services from a holistic, comprehensive perspective, to understand there is a role for RPNs - Registered Practical Nurses - in our hospitals for example"
Hoskins says the decisions about staffing need to be made a the local level through the LHINS and hospital management.

He says Windsor Regional is one of just a few hospitals around the province that hasn't yet made that transition, recognizing and "quite frankly respecting" the role of Registered Practical Nurses.
Hoskins points out the province provided $7-million in additional funding to help the hospital transition through the change.

Support Windsor Regional Hospital RNs!

Send your email now!

Registered nurses (RNs) have special skills that are crucial for patients with complex needs. Yet Windsor Regional Hospital is cutting 169 RNs to save money. That’s more than 300,000 hours of care, and 10 per cent of the RNs serving our community. In fact, RNs, save our system money in the long run by preventing patient complications and costly readmissions. Fewer RNs means an increased risk of complications including bedsores, sepsis, blood clots, pneumonia, cardiac arrest and even death. The hospital is struggling because funding has been frozen since 2012.
We shouldn’t be balancing the books at the expense of patients.
Please join our call to stop the cuts and ensure hospitals can continue to provide the care patients need.

Join the Virtual Rally to Stop the Cuts!


Nurses across the province are saying enough is enough. Join our virtual rally by signing up to post a campaign message on Facebook or Twitter at a coordinated date and time: #NursesKnow #OnPoli

Tuesday, February 23, 2016

Monday, February 22, 2016

Patients pay the price for cutting cost

ER overhaul hits snag

ER overhaul hits snag

By Jonathan Sher, The London Free Press
Registered nurses James Gibbons, Alan Warrington, Kathy Burgess, and union head James Murray, l-r, in front of the emergency department of Victoria Hospital.  Photo taken on Monday Feb 22, 2016 (MORRIS LAMONT, The London Free Press)
Registered nurses James Gibbons, Alan Warrington, Kathy Burgess, and union head James Murray, l-r, in front of the emergency department of Victoria Hospital. Photo taken on Monday Feb 22, 2016 (MORRIS LAMONT, The London Free Press)
Nine months after London’s largest hospital took a hammer to its emergency rooms and turned to methods of auto giant Toyota to speed patients through, that project has hit delays.
London Health Sciences Centre had hoped by March to complete changes that would break an ER logjam that had been among the worst in Ontario — but that target now has been pushed back to later this year.
The delay isn’t the only challenge: The union that represents front-line registered nurses is accusing the hospital of funding the Toyota plans by downgrading the calibre of nurses who treat the mentally ill in ERs.
“We just spent millions of dollars to try to implement Toyota,” said James Murray, a registered nurse and president of Local 100 of the Ontario Nurses’ Association that represents 3,600 nurses in London. “It’s wasted money.”
Five registered nurses who care for those with mental illness in the emergency room will be replaced by cheaper, less educated registered practical nurses (RPNs), he said.
Though RPNs have valuable skills, they can’t replace RNs tasked with making tough calls about those with mental illness, including whether to restrain them through the use of medication or physical devices
“(RPNs are) not going to be able to pick up the subtle clues,” Murray said.
But hospital CEO Murray Glendining says the change won’t compromise safety and that the money saved had nothing to do with the Toyota plan.
As for the delay, that’s because the plan required changes to how care is provided in homes, the community and long-term care, and those changes aren’t complete.
“We are not abandoning the (Toyota plan),” Glendining told The Free Press.
In order to move patients through the ER more quickly, the hospital must speedily treat those who can be released while securing ward beds for those who will need to be admitted. The first part of that plan has gone well — Glendining says the December results were spectacular — but the second part is challenging,
When there is not enough support for people to be cared for in their homes, communities and nursing homes, patients who should be discharged are not — creating a bottleneck that backs up the ER with patients waiting for a bed on a ward.
“(The plan) is much bigger than just the emergency department,” Glendining said.
The percentage of patients waiting to be safely discharged from a ward has remained stubbornly high and recently spiked again, he said.
But Murray isn’t convinced Toyota changes help patients, pointing to a review of all previous studies on similar efficiency changes that found little evidence that such changes make a difference.
“While some may strongly believe (these) interventions lead to quality improvements in health care, the evidence to date simply does not support this claim. More rigorous, higher quality and better conducted scientific research is required,” researchers in Saskatchewan wrote in a study published in the International Journal for Quality in Health Care Advance Access.

Tired doctors: How your doctor’s schedule could harm your health

Tired doctors: How your doctor’s schedule could harm your health

Trouble with the video? Watch it on YouTube here.
Do tired and overworked doctors on marathon shifts make more mistakes? It’s a nightmare that many people don’t think about: How your doctor’s schedule may be harming your health. Sleepless shifts of up to 30 hours are routine for many of Canada’s 12,000 resident doctors. And that’s unacceptable and dangerous, according to a panel of medical experts. But Canada has no national standard for the hours residents work. David Common and two doctors stay awake and put themselves to the test in a 26-hour sleep lab experiment, to test how sleep deprivation can affect even the best doctors.

Saturday, February 20, 2016

Nominees sought for ninth annual nursing award

Nominees sought for ninth annual nursing award

Lois Fairley, a nurse at Grace Hospital from 1954 to 1993, is pictured in this handout photo. Each year in Windsor-Essex, an outstanding nurse is awarded the Lois Fairley Nursing Award. Handout / Windsor Star
Share Adjust Comment Print
Nominations are now being accepted for the ninth annual Lois Fairley Nursing Award, which honours outstanding nurses in Windsor and Essex County.
Presented by the Windsor-Essex chapter of the Registered Nurses’ Association of Ontario, nominations are received from the community.
If you a know a nurse who has made an impact in their workplace or in the lives of a patient or family member, nominate them by writing your story in 500 words or less.
For more information or to access the nomination form, visit
Deadline for the entries is 5 p.m. on April 1.
The award is named in honour of Lois Fairley, a Registered Nurse who started and finished her 38 year nursing career at Grace Hospital in Windsor from 1955 to 1993.
Fairley died in 2007 and the Registered Nurses Association of Ontario established the award in 2008.
Last year’s winner was Rita DiBiase.
Rita Di Biase, left, is presented with the 2015 Registered Nurses Association of Ontario, Windsor-Essex Lois A. Fairley Nursing Award by Dana Boyd and last years winner Ava Lewis at the Leamington Hospital on Wednesday, April 22, 2015.
Rita Di Biase, left, is presented with the 2015 Registered Nurses Association of Ontario, Windsor-Essex Lois A. Fairley Nursing Award by Dana Boyd and last years winner Ava Lewis at the Leamington Hospital on Wednesday, April 22, 2015. Tyler Brownbridge / Windsor Star

Tuesday, February 16, 2016

What is Ailing Ontario Health Care? Nurses Know

FOR IMMEDIATE RELEASE                                                                            February 16, 2016

What is Ailing Ontario Health Care?
Nurses Know

TORONTO – Ontario registered nurses know what is ailing Ontario's health-care system and urge the public to recognize and speak out regarding the special role their care plays in health care.

On Family Day, the Ontario Nurses' Association (ONA) launched new television, radio, transit, print and social media ads across the province. The ads celebrate the dedication, knowledge and skills registered nurses (RNs) possess and the challenges they face as they provide quality, compassionate care.

ONA President Linda Haslam-Stroud, RN, says that ONA's Nurses Know campaign, "says it all in one, simple phrase. Nurses know what is ailing our health-care system. Nurses also know the cure. As this province continues to starve hospitals of funding, nurses know the impact on patients. By signing our on-line petition, Ontarians can support our call for an end to RN cuts, restoration of adequate hospital funding and a funded, multi-year plan to increase the ratio of RNs-to-population.

"Hospitals across Ontario continue to announce round after round of RN cuts, 406 of them in 2016 alone, leaving patients vulnerable to an increased risk of suffering complications and death," says Haslam-Stroud.  "Nurses know that patient care is suffering because we see it on the front lines each and every day. The question is, do we value our health care enough to speak out against the cuts that are doing so much harm?"

The campaign focus is on the professionalism of RNs, their medical knowledge and advanced education that qualifies them to care for patients suffering from complex illnesses with unpredictable outcomes, like patients in hospitals. ONA urges concerned Ontarians to take action for better care by signing an on-line petition or contacting their MPP.

ONA's 60,000 registered nurses and allied health professional members, nursing students, friends and supporters will be taking the campaign to their local communities, holding events to engage their communities, speaking to decision-makers and local media.

"Nurses know that every patient deserves the best quality care possible," Haslam-Stroud says. "RNs will continue to try to make Ontario's health-care system better, and we ask Ontarians to join us."

Visit to learn more, view the ads and take action.

ONA is the union representing 60,000 registered nurses and allied health professionals, as well as more than 14,000 nursing student affiliates, providing care in hospitals, long-term care facilities, public health, the community, clinics and industry.       

Monday, February 15, 2016

February 15th - Windsor ONA Information Picket

A big thank you to all who joined us today!

 Despite the freezing rain, light snow and cold temperatures, around 150 members, friends, family, doctors, RPNs, ward clerks and fellow brothers and sisters from other unions [sorry if I missed anyone!] helped spread the word that cuts to health care are bad for the people of Windsor Essex County and Ontario.

Also thank you Karen McCullough CNE and Ralph Nicoletti, VP for coming out to support us. The donation of coffee from our fellow unionists and WRH was very much appreciated during our pickets.

Today many petitions were collected nearly 1000 signatures were added to the nearly 4000 we have collected or had submitted online. Please keep the pressure on by getting more signatures or having concerned citizens go online to sign the petition

Together we are stronger - for more pictures of the picket check out our ONA Local 8 Google Plus profile for more pictures!

Special thanks to Sherri who had these great t-shirts made at her own expense! They were the highlight of the day!

Friday, February 12, 2016

International Women's Day - March 8th

Celebrate International Women's Day
Canada's theme: Women’s Empowerment Leads to Equality
Empowerment is essential to gender equality. Women and girls who are empowered are better equipped to fulfill their potential and contribute their best to society.
So, what is empowerment?
Empowerment is having the tools to make better choices.
Empowered women make choices that meet their own needs and those of their families. When this happens, the world becomes a better place – not just for women, but for all of us.
Empowerment includes:
Having access to education.
Women who have access to educational opportunities are more likely to participate in the labour market and strengthen outcomes for themselves, their families, their communities and the economy.
Getting involved in the community.
When women and girls get involved in the daily life of their communities, they learn more about the people and opportunities around them and are able to share their talents and perspectives.
Becoming financially independent.
When women have the knowledge and means to support themselves, they are more able to make financial decisions that will improve their quality of life.
Understanding your right to live free from violence.
Women and girls who feel safe and secure in their homes and communities are more able to participate in all aspects of life.
Knowing how government works and exercising your democratic rights.
Women who have the opportunity to participate in the democratic life of their country influence its governance, taking into account their rights, needs and values.
When women and girls have the opportunities and resources to succeed, it enriches all of society. We are all stronger when women and girls are empowered!
A century of voting rights
Photo credit: Library and Archives Canada
The right to vote and to run for office is a fundamental aspect of women’s empowerment. In 1916, Manitoba became the first Canadian province to grant women the right to vote in provincial elections. In 2016, Canada is recognizing the significance of this milestone by celebrating the centennial of women’s suffrage and reflecting on how this historic event has influenced women’s empowerment and gender equality

Ontario Nurses Say Enough is Enough - Concessions and Layoffs Must Stop Now

FOR IMMEDIATE RELEASE                                                                                          
 February 12, 2016

Ontario Nurses Say Enough is Enough
 Concessions and Layoffs Must Stop Now

TORONTO Ontario nurses say enough is enough following three futile weeks of bargaining with the Ontario Hospital Association (OHA). Contract talks came to an abrupt halt when the OHA team made a final offer which would result in the gutting of our wages, benefits and job security. 

The union representing more than 58,000 hospital RNs has been clear from day one that RN workloads and lack of staffing are at crisis levels and something must be done immediately to stop the unprecedented wave of RN cuts, says ONA President Linda Haslam-Stroud, RN. The current collective agreement between ONA's hospital-sector RNs and their employers expires on March 31.

Haslam-Stroud is appalled at what has been tabled by the employer. She says that, "we will not bargain away our future or our ability to provide quality patient care. Neither are we prepared to devalue the contributions made by these crucial professionals." ONA stands firm in our commitment to negotiate an agreement that fairly reflects the contribution that RNs make to our patients.    

Ontario's nurses are calling on the provincial government to give hospitals a wake-up call about the integral role that RNs play in the government's "Patients First" agenda. Registered Nurses have had enough of staffing shortages leading to death and disease, escalating workloads and violence. Nurses continue to suffer from work environments that contribute to the highest injury and illness rates of any profession.

Unsafe RN staffing levels have become more common as hospitals have cut RN positions to balance budgets; increasingly, RNs are finding they are unable to provide care consistent with the standards set by their regulator. Ontario has cut more than 1,200 RN positions in the past 13 months.

The message from Ontario's nurses is crystal clear: Our patients deserve better!

ONA is the union representing 60,000 registered nurses and allied health professionals, as well as more than 14,000 nursing student affiliates, providing care in hospitals, long-term care facilities, public health, the community, clinics and industry.