The performance metrics show a consistent decline in the accuracy of spirometry readings across multiple testing sites within a regional health network. This scenario is professionally challenging because it directly impacts patient care, potentially leading to misdiagnosis or inappropriate treatment decisions. Maintaining high-quality pulmonary function testing is paramount for accurate clinical assessment and research validity. Careful judgment is required to identify the root cause of the decline and implement effective solutions that align with professional standards and regulatory expectations for quality assurance in diagnostic testing. The best approach involves a systematic, multi-faceted quality improvement initiative. This includes a comprehensive review of existing protocols, equipment calibration logs, and staff training records. It necessitates direct observation of testing procedures at affected sites, followed by targeted retraining and equipment servicing where deficiencies are identified. Furthermore, establishing a feedback loop for ongoing monitoring and data analysis is crucial to ensure sustained accuracy and compliance with best practices in pulmonary function technology. This aligns with the ethical obligation to provide competent care and the regulatory expectation for robust quality management systems in healthcare settings, ensuring patient safety and the reliability of diagnostic data for clinical and research purposes. An incorrect approach would be to solely rely on automated software alerts without investigating the underlying causes. While alerts are useful, they do not provide insight into why the errors are occurring. This fails to address potential issues with equipment, technique, or training, thereby neglecting the professional responsibility to ensure accurate testing and potentially violating quality assurance guidelines that mandate proactive problem-solving. Another incorrect approach is to implement a blanket retraining program for all staff without first identifying specific areas of weakness. This is inefficient and may not address the actual root causes of the performance decline, which could be localized to specific equipment or sites. It represents a failure to apply a targeted and evidence-based quality improvement strategy, which is a cornerstone of professional practice in diagnostic technology. A further incorrect approach would be to dismiss the performance metrics as statistical anomalies without further investigation. This demonstrates a lack of diligence and a disregard for data that indicates potential systemic issues. It fails to uphold the professional commitment to continuous improvement and patient safety, potentially leading to prolonged periods of inaccurate testing and compromised patient outcomes. Professionals should employ a structured problem-solving framework, such as Plan-Do-Check-Act (PDCA), when faced with performance metric deviations. This involves identifying the problem, developing and implementing solutions, monitoring their effectiveness, and standardizing successful interventions. This systematic approach ensures that quality improvement efforts are data-driven, efficient, and sustainable, ultimately benefiting patient care and research integrity.

Scenario Analysis: This scenario presents a professional challenge in ensuring candidates are adequately prepared for the Applied Caribbean Pulmonary Function Technology Proficiency Verification. The challenge lies in balancing the need for comprehensive preparation with the practical constraints of time and resource availability for candidates. Effective guidance requires an understanding of the examination’s scope, the typical learning curves associated with pulmonary function technology, and the importance of adhering to established professional development standards within the Caribbean region. Misinformation or inadequate guidance can lead to candidate failure, wasted resources, and a potential deficit in qualified pulmonary function technologists, impacting patient care. Correct Approach Analysis: The best professional practice involves recommending a structured, multi-faceted preparation strategy that aligns with the examination’s stated objectives and the typical learning pathways for pulmonary function technologists. This approach emphasizes a phased timeline, beginning with a thorough review of foundational knowledge and progressing to practical application and simulated testing. It advocates for utilizing official study guides, reputable textbooks, and potentially accredited training modules, while also encouraging peer-to-peer learning and seeking mentorship from experienced professionals. This comprehensive method ensures that candidates not only understand the theoretical underpinnings but also develop the practical skills and diagnostic interpretation abilities required by the verification, thereby maximizing their chances of success and upholding professional standards. Incorrect Approaches Analysis: Recommending a last-minute cramming session, focusing solely on memorizing facts without understanding concepts, or relying exclusively on unofficial, potentially outdated, or inaccurate online forums would be professionally unacceptable. Such approaches fail to address the depth and breadth of knowledge and skills assessed by a proficiency verification. They neglect the importance of a systematic learning process, which is crucial for developing the diagnostic reasoning and practical competence expected of a pulmonary function technologist. Furthermore, relying on unverified resources can lead to the acquisition of incorrect information, directly contravening the ethical obligation to provide accurate guidance and potentially leading to examination failure and a compromised standard of practice. Professional Reasoning: Professionals should approach candidate preparation guidance by first thoroughly understanding the specific requirements and scope of the examination. This involves consulting official documentation and understanding the underlying competencies being assessed. Next, they should consider the typical learning progression for the profession, recognizing that proficiency is built over time through a combination of theoretical study, practical experience, and skill refinement. Guidance should then be tailored to facilitate this progression, recommending a balanced approach that includes reviewing core knowledge, engaging in practical exercises, and utilizing validated resources. A critical element of professional decision-making is to prioritize accuracy, reliability, and the long-term development of the candidate’s competence, rather than offering shortcuts that compromise the integrity of the verification process.

Scenario Analysis: This scenario presents a professional challenge in accurately assessing pulmonary function in a patient with a history of thoracic trauma. The presence of altered chest wall mechanics and potential underlying parenchymal damage due to the trauma introduces significant complexity. It requires the pulmonary function technologist to move beyond standard protocol and critically evaluate how these physiological changes might impact test results, necessitating a nuanced approach to data interpretation and reporting. The challenge lies in distinguishing between true physiological impairment and artifactual changes caused by the trauma’s sequelae. Correct Approach Analysis: The best professional practice involves a comprehensive approach that integrates the patient’s clinical history, specifically the details of the thoracic trauma and its impact on biomechanics, with the pulmonary function test (PFT) results. This approach necessitates careful observation of the patient’s breathing pattern during the test, noting any signs of discomfort, paradoxical movement, or effort limitations directly attributable to the trauma. The technologist should then correlate these observations with the obtained PFT values, considering how altered chest wall compliance, reduced lung volumes, or dynamic hyperinflation might manifest. Reporting should include a clear statement acknowledging the history of trauma and its potential influence on the PFT results, alongside the objective findings. This aligns with ethical obligations to provide accurate and contextually relevant patient care, ensuring that diagnostic interpretations are not made in isolation but are informed by the patient’s unique physiological state. Regulatory guidelines for PFT practice emphasize the importance of patient assessment and the accurate reporting of findings, which implicitly includes accounting for factors that may significantly alter test performance and results. Incorrect Approaches Analysis: One incorrect approach is to proceed with standard PFT protocols without any specific consideration for the thoracic trauma, interpreting all results as purely indicative of intrinsic lung disease. This fails to acknowledge the significant biomechanical alterations that trauma can induce, potentially leading to misdiagnosis or inappropriate treatment. It violates the professional duty to conduct a thorough patient assessment and to report findings with appropriate context. Another incorrect approach is to solely rely on the numerical PFT values and disregard any observed limitations or unusual breathing patterns during the test. This approach ignores crucial qualitative data that can explain deviations from expected results and may lead to an overestimation or underestimation of functional impairment. It is ethically unsound as it prioritizes raw data over a holistic understanding of the patient’s condition. A further incorrect approach is to attribute all deviations in PFT results directly to the trauma without attempting to differentiate between trauma-induced biomechanical limitations and actual parenchymal lung disease. While the trauma is a significant factor, it is essential to use PFTs to assess the current functional status of the lungs themselves, even if that status is influenced by the trauma. This approach risks oversimplifying a complex physiological picture and may obscure underlying or co-existing pulmonary pathology. Professional Reasoning: Professionals should adopt a systematic decision-making process that begins with a thorough review of the patient’s medical history, paying close attention to any factors that could influence pulmonary mechanics or lung function. During the PFT, meticulous observation of the patient’s effort, breathing pattern, and any signs of distress is paramount. This qualitative data should then be integrated with the quantitative PFT results. When interpreting and reporting findings, the technologist must consider the interplay between the patient’s history, observed performance, and the test data. Any potential impact of the patient’s condition on the validity or interpretation of the results should be clearly communicated to the referring physician. This ensures that diagnostic and therapeutic decisions are based on the most accurate and complete information available.

Scenario Analysis: This scenario presents a professional challenge in ensuring that individuals seeking to verify their proficiency in Applied Caribbean Pulmonary Function Technology meet the established criteria. The challenge lies in balancing the need for accurate and reliable verification with the practicalities of assessing diverse backgrounds and experience levels. Careful judgment is required to interpret the purpose and eligibility requirements of the verification process in a way that upholds professional standards without creating undue barriers. Correct Approach Analysis: The best professional practice involves a thorough review of the applicant’s documented training, practical experience, and any relevant certifications against the explicit purpose and eligibility criteria for the Applied Caribbean Pulmonary Function Technology Proficiency Verification. This approach is correct because it directly aligns with the stated objectives of the verification process, which is to confirm a baseline level of competence and knowledge in pulmonary function technology relevant to the Caribbean context. Adhering to these documented criteria ensures fairness, consistency, and the integrity of the verification process, preventing the inclusion of individuals who may not possess the necessary foundational skills or understanding. This upholds the professional standards expected by regulatory bodies and the public. Incorrect Approaches Analysis: One incorrect approach is to grant eligibility based solely on the applicant’s self-declaration of having “worked in a related field for a significant period,” without requiring any objective evidence or specific alignment with pulmonary function technology. This fails to meet the purpose of the verification, which is to assess specific proficiency, not general healthcare experience. It bypasses the established eligibility criteria and risks allowing unqualified individuals to be certified, undermining the credibility of the verification. Another incorrect approach is to prioritize applicants who have completed extensive training in pulmonary function technology in regions outside the Caribbean, even if their training does not specifically address regional protocols or common conditions prevalent in the Caribbean. While extensive training is valuable, the purpose of this specific verification is to ensure proficiency within the Caribbean context. Ignoring this specific requirement, even with strong external credentials, means the applicant may not meet the intended scope of the verification. A further incorrect approach is to assume that a general medical technician certification automatically qualifies an individual for Applied Caribbean Pulmonary Function Technology Proficiency Verification. General certifications often cover a broad range of medical tasks and do not guarantee specialized knowledge or practical skills in pulmonary function testing. This approach fails to acknowledge the specific and distinct nature of pulmonary function technology and its associated verification requirements. Professional Reasoning: Professionals should approach eligibility assessments by first clearly understanding the stated purpose of the verification process. This involves identifying the specific skills, knowledge, and experience the verification aims to confirm. Next, they must meticulously examine the defined eligibility criteria, paying close attention to any specific requirements related to training, experience, or regional context. When evaluating an applicant, professionals should seek objective evidence that directly supports their claim of meeting these criteria. If there is ambiguity, seeking clarification from the governing body or referring to official guidelines is paramount. The decision-making process should prioritize adherence to established standards and the integrity of the verification process over assumptions or convenience.

The performance metrics show a significant number of candidates failing the Applied Caribbean Pulmonary Function Technology Proficiency Verification exam, particularly in areas related to blueprint weighting, scoring, and retake policies. This scenario is professionally challenging because it directly impacts the integrity of the certification process and the competence of pulmonary function technologists in the Caribbean region. Ensuring fair and accurate assessment, while maintaining rigorous standards, requires a deep understanding of the examination’s design and administration. Careful judgment is needed to interpret performance data and implement appropriate corrective actions without compromising the validity of the certification. The best professional practice involves a comprehensive review of the examination blueprint and scoring mechanisms to identify any potential discrepancies or biases that might be contributing to the high failure rates. This approach prioritizes a thorough, evidence-based investigation into the examination’s design and implementation. Specifically, it entails examining whether the blueprint accurately reflects the essential knowledge and skills required for competent practice, and if the weighting of different sections aligns with their importance. Furthermore, it requires scrutinizing the scoring rubric for clarity, objectivity, and consistency, and evaluating the retake policy to ensure it is fair, supportive of candidate learning, and does not unduly penalize individuals. This aligns with the ethical obligation to provide a valid and reliable assessment that accurately measures proficiency. An incorrect approach would be to immediately revise the retake policy to allow unlimited attempts without investigating the root cause of the failures. This fails to address potential flaws in the examination content or scoring, thereby perpetuating the problem and potentially certifying individuals who may not meet the required standards. It also overlooks the ethical responsibility to ensure the assessment itself is sound. Another incorrect approach would be to solely focus on candidate preparation, suggesting that all failures are due to insufficient study without considering whether the examination itself is appropriately designed or administered. This places the entire burden on the candidate and ignores the responsibility of the certifying body to provide a fair and valid assessment. Finally, an approach that involves arbitrarily lowering the passing score without a systematic review of the blueprint and scoring would undermine the credibility of the certification and devalue the proficiency it aims to verify. Professionals should employ a systematic decision-making framework that begins with data analysis to identify the problem. This should be followed by a thorough investigation into the examination’s design, content, and administration, considering all aspects from blueprint weighting to retake policies. Stakeholder feedback, including from candidates and examiners, should be solicited and considered. Any proposed changes should be evidence-based, ethically sound, and aimed at improving the validity and reliability of the assessment while ensuring fairness to candidates.

Scenario Analysis: This scenario presents a professional challenge because it requires the allied health professional to balance the immediate need for accurate diagnostic information with the ethical and regulatory obligations to patient privacy and consent. The performance metrics highlight a potential conflict between efficiency goals and patient rights, demanding careful judgment to ensure both are met. Correct Approach Analysis: The best professional practice involves obtaining explicit, informed consent from the patient for the specific use of their pulmonary function test data, even when it is for internal performance metric analysis. This approach upholds the principle of patient autonomy and adheres to data protection regulations that mandate consent for the processing of personal health information. By clearly explaining the purpose of data collection and usage, and obtaining documented consent, the professional ensures transparency and respects the patient’s right to control their own health data. This aligns with the ethical duty of care and the regulatory framework governing patient data in allied health settings. Incorrect Approaches Analysis: One incorrect approach involves using the patient’s data for performance metrics without their explicit knowledge or consent, assuming it is implied by the provision of the service. This violates patient privacy rights and data protection regulations, which typically require specific consent for data usage beyond direct clinical care. It erodes patient trust and can lead to regulatory penalties. Another incorrect approach is to anonymize the data so thoroughly that it cannot be linked back to the patient, but to do so without first obtaining consent for any use of the data, even anonymized. While anonymization can be a protective measure, the initial collection and subsequent use of the data, even in an anonymized form, may still require a basis, such as consent or a clear legal justification, depending on the specific regulatory context. Proceeding without any form of consent or clear legal basis for data use is a failure. A third incorrect approach is to rely solely on institutional policy that permits the use of such data for performance metrics without verifying if that policy itself aligns with current patient consent and data protection legislation. Institutional policies must be compliant with overarching legal and ethical standards. Relying on a potentially non-compliant policy is a regulatory and ethical failure. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes patient rights and regulatory compliance. This involves: 1) Identifying all applicable regulations and ethical guidelines related to patient data and consent. 2) Assessing the specific use of the data and its potential impact on patient privacy. 3) Proactively seeking informed consent from patients for any use of their data beyond direct clinical care. 4) Documenting all consent processes and data handling procedures. 5) Regularly reviewing institutional policies to ensure they remain compliant with evolving legal and ethical standards.

Scenario Analysis: This scenario presents a professional challenge due to the critical nature of pulmonary function testing (PFT) in diagnosing and managing respiratory conditions. Inaccurate or misinterpreted results can lead to misdiagnosis, delayed treatment, or inappropriate interventions, directly impacting patient outcomes. The challenge lies in ensuring the highest standard of diagnostic accuracy and patient care within the established technological and regulatory framework. Careful judgment is required to select the most appropriate diagnostic approach based on the available information and best practices. Correct Approach Analysis: The best professional practice involves a comprehensive evaluation of the patient’s clinical presentation, medical history, and the specific diagnostic question being asked, before selecting the most appropriate PFT modality. This approach ensures that the chosen test is not only technically feasible but also clinically relevant and likely to yield the most accurate and actionable diagnostic information. This aligns with the ethical imperative to provide competent and evidence-based care, and implicitly with regulatory expectations that practitioners utilize diagnostic tools judiciously and effectively to serve patient interests. The focus is on patient-centered care and the judicious application of technology. Incorrect Approaches Analysis: One incorrect approach is to solely rely on the most advanced or readily available instrumentation without considering its specific diagnostic utility for the patient’s presenting symptoms. This can lead to the performance of tests that are unnecessary, may not provide the required diagnostic information, or could even yield misleading results if not interpreted within the correct clinical context. This fails to uphold the principle of providing appropriate and necessary care, potentially wasting resources and delaying accurate diagnosis. Another incorrect approach is to prioritize speed of testing over thoroughness and accuracy. While efficiency is important, compromising the quality of data acquisition or interpretation to expedite results is professionally unacceptable. This can lead to errors in diagnosis and treatment, violating the duty of care owed to the patient. Regulatory frameworks emphasize accuracy and reliability in diagnostic procedures. A further incorrect approach is to assume that a single PFT modality will always provide a definitive answer for all respiratory complaints. Respiratory diseases can be complex and multifactorial, often requiring a combination of diagnostic tools or a stepwise approach to arrive at a diagnosis. Relying on a single, potentially insufficient test without considering alternatives or complementary investigations can lead to incomplete or incorrect diagnoses. Professional Reasoning: Professionals should adopt a systematic decision-making process that begins with a thorough understanding of the patient’s clinical situation. This involves active listening to the patient’s concerns, reviewing their medical history, and considering the differential diagnoses. Based on this comprehensive assessment, the professional should then identify the specific diagnostic questions that need to be answered. Subsequently, they should evaluate the available PFT technologies and their known capabilities and limitations in addressing those specific questions. The selection of the PFT modality should be guided by its ability to provide accurate, reliable, and clinically relevant data that will directly contribute to patient management. This process ensures that diagnostic efforts are targeted, efficient, and ultimately beneficial to the patient, adhering to both ethical principles and regulatory expectations for quality healthcare.

The efficiency study reveals a critical juncture in the implementation of new pulmonary function technology. This scenario is professionally challenging because it requires balancing the pursuit of technological advancement and improved patient care with the imperative of ensuring that all staff are adequately prepared and competent to operate the new equipment safely and effectively. Rushing implementation without proper training can lead to diagnostic errors, patient harm, and potential regulatory non-compliance. Careful judgment is required to determine the most responsible and effective path forward. The best professional practice involves a phased approach to technology integration that prioritizes comprehensive staff training and competency validation before full operational deployment. This approach ensures that all healthcare professionals using the new equipment possess the necessary knowledge and skills to operate it accurately and interpret results reliably. Regulatory frameworks, such as those governing medical device use and patient safety, implicitly require that healthcare providers maintain competence in the technologies they employ. Ethically, this approach upholds the principle of non-maleficence by minimizing the risk of harm to patients due to operator error. It also promotes beneficence by ensuring that the benefits of the new technology are realized through accurate and reliable application. An approach that involves immediate deployment of the new technology across all departments with only basic introductory sessions for staff is professionally unacceptable. This fails to meet the implicit regulatory requirement for demonstrated competency and directly contravenes ethical principles by exposing patients to potential diagnostic inaccuracies and harm due to insufficient operator skill. Similarly, an approach that delays the implementation indefinitely due to minor technical glitches, without a clear plan for addressing them and proceeding with training, is also professionally unsound. This can lead to a stagnation of care, preventing patients from benefiting from potentially superior diagnostic capabilities, and may also be seen as a failure to adopt best available practices, which could have regulatory implications if it leads to suboptimal patient outcomes compared to facilities utilizing the new technology. Finally, an approach that focuses solely on the cost-effectiveness of the new technology without adequately considering the training and competency needs of the staff overlooks a fundamental aspect of successful technology adoption and patient safety, potentially leading to regulatory scrutiny for inadequate risk management. Professionals should employ a decision-making framework that begins with a thorough risk assessment of any new technology implementation. This assessment must include the potential impact on patient care, the required staff competencies, and the available resources for training and support. Following this, a structured implementation plan should be developed, prioritizing comprehensive, hands-on training and competency validation for all relevant personnel. Regular review and feedback mechanisms should be integrated to ensure ongoing proficiency and address any emerging issues, aligning with both regulatory expectations for safe and effective practice and ethical obligations to patient well-being.

Scenario Analysis: This scenario is professionally challenging because it requires the technologist to integrate complex physiological data with potential clinical implications, necessitating a nuanced understanding of both the data’s limitations and the patient’s overall clinical context. The pressure to provide timely and accurate interpretations, while adhering to professional standards and patient confidentiality, demands careful judgment. Misinterpretation or overreliance on automated analysis can lead to delayed or inappropriate clinical decisions, impacting patient care. Correct Approach Analysis: The best professional practice involves a comprehensive review of the raw pulmonary function test (PFT) data, including flow-volume loops and time-volume curves, alongside the patient’s clinical history, symptoms, and any other relevant diagnostic information. This approach ensures that the interpretation is not solely based on numerical results but is contextualized within the individual patient’s presentation. This aligns with the ethical imperative to provide patient-centered care and the professional responsibility to ensure the accuracy and clinical relevance of PFT interpretations. Regulatory guidelines, such as those from professional bodies governing respiratory care, emphasize the importance of integrating all available information for a complete and accurate assessment. Incorrect Approaches Analysis: Relying solely on the automated interpretation provided by the PFT software, without reviewing the raw data and clinical context, is professionally unacceptable. This approach risks overlooking subtle abnormalities or artifacts in the tracing that the software may not detect, leading to inaccurate conclusions. It also fails to account for individual patient variability and specific clinical presentations that might influence the interpretation of standard values. Furthermore, presenting the automated interpretation as a definitive diagnosis without independent clinical correlation breaches professional standards of care and potentially violates patient safety principles. Another incorrect approach would be to focus exclusively on the numerical results while disregarding the visual tracings and the patient’s reported symptoms. This overlooks crucial qualitative aspects of the PFTs that can provide significant diagnostic clues and fails to consider the patient’s subjective experience, which is vital for a holistic clinical assessment. Finally, sharing the raw data or preliminary interpretations with unauthorized individuals or without proper patient consent would constitute a breach of patient confidentiality, violating privacy regulations and ethical obligations. Professional Reasoning: Professionals should adopt a systematic approach to data interpretation. This involves first ensuring the technical quality of the test by reviewing tracings for artifacts. Subsequently, compare the obtained values against appropriate reference ranges, considering patient demographics. Crucially, integrate these findings with the patient’s clinical history, symptoms, and other diagnostic data. If automated software is used, it should be treated as a supportive tool, not a replacement for expert clinical judgment and data review. Any discrepancies or uncertainties should prompt further investigation or consultation with a qualified clinician.

The control framework reveals a critical scenario in a pulmonary function testing (PFT) facility where a technician has identified a potential breach in infection control protocols. This situation is professionally challenging because it directly impacts patient safety, the integrity of test results, and the reputation of the facility. The technician must balance the immediate need to address the breach with established protocols for reporting and resolution, ensuring that patient well-being is paramount while adhering to regulatory standards. Careful judgment is required to determine the most appropriate course of action that upholds the highest standards of care and compliance. The best professional practice involves immediately isolating the potentially contaminated equipment and notifying the designated supervisor or infection control officer, as per established facility policy and relevant public health guidelines for healthcare settings. This approach ensures that the risk of further transmission is mitigated without delay. It aligns with the fundamental ethical principle of non-maleficence (do no harm) and the regulatory requirement for healthcare facilities to maintain a safe environment for patients and staff. Prompt reporting allows for a systematic investigation, proper decontamination or disposal of equipment, and implementation of corrective actions to prevent recurrence, thereby upholding quality control standards. An incorrect approach would be to proceed with testing using the potentially contaminated equipment while awaiting further instructions. This action demonstrates a failure to prioritize patient safety and a disregard for infection prevention protocols. It violates the ethical duty to protect patients from harm and contravenes regulatory mandates that require strict adherence to infection control measures in healthcare environments. Such a lapse could lead to cross-contamination, resulting in misdiagnosis, patient harm, and significant legal and reputational consequences for the facility. Another unacceptable approach is to attempt to clean the equipment independently without following established decontamination procedures or reporting the incident. This bypasses the facility’s quality control mechanisms and may result in inadequate sterilization, leaving residual contaminants. It also obstructs the facility’s ability to track and address potential breaches, hindering continuous quality improvement efforts and potentially violating regulatory requirements for incident reporting and documentation. Finally, ignoring the potential breach and continuing with normal operations without any intervention is professionally negligent. This demonstrates a severe lack of commitment to patient safety and quality control. It directly contravenes ethical obligations to act in the best interest of the patient and violates numerous regulatory requirements that mandate proactive identification and management of risks within healthcare settings. Such inaction can have devastating consequences for patient health and the facility’s operational integrity. Professionals should employ a decision-making framework that prioritizes patient safety and regulatory compliance. This involves: 1) immediate identification and containment of the potential risk; 2) prompt and accurate reporting to the appropriate authority within the facility; 3) adherence to established protocols for investigation and resolution; and 4) participation in corrective and preventative actions. This systematic approach ensures that patient well-being is protected, regulatory standards are met, and the overall quality of care is maintained.