Monte has national level program trying to move towards more epherent limb nurses working with individual dept to make srue all cases are reviewed trickles up to baoard id problem docs, id system issues (what recurs) decide what resources should be allocated 2-3 quality nurses focused solely on quality improvement assurance focused on fixes trying to move to this when cases presented to board try to focus on fix and system issue whether it's IT education restructuring using these things to reflect on larger structural stuff is right way to change and direction to go looking at htem prioriting them