Quality of Care and Patient Outcomes What is accreditation?
Accreditation is a voluntary survey process used by
various NONGOVERNMENTAL, INDEPENDENT EXTERNAL AGENCIES to assess the extent of a healthcare organization's compliance with applicable pre- established performance standards set by the agency. Accreditation review is CONDUCTED BY INDUSTRY PROFESSIONALS (e.g., Physicians, nurses, pharmacists, dieticians, administrators, life safety code specialists) who, through written reports, publicly attest to the resulting accreditation status. Accreditation is often a VOLUNTARY PROCESS in which organizations choose to participate, rather than one required by law and regulation. What is accreditation? Accreditation standards are usually regarded as optimal and achievable. Accreditation provides A VISIBLE COMMITMENT BY AN ORGANIZATION to improve the quality of patient care, ensure a safe environment, and continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an EFFECTIVE quality evaluation and management tool. The purpose of accreditation is to IMPROVE THE SYSTEMS AND PROCESSES of care and, in so doing, improve patient outcomes. Accreditation Is Not An Alternative To Licensure
Licensure is a process by which a governmental
authority grants PERMISSION TO AN INDIVIDUAL PRACTITIONER OR HEALTH CARE ORGANIZATION to operate or to engage in an occupation or profession.
Licensure regulations are generally established to
ensure that an organization or individual meets minimum standards to protect public health and safety And Is Not Certification Certification is a process by which an authorized body, either a governmental or non-governmental organization, evaluates and recognizes either an individual or an organization as meeting pre-determined requirements or criteria.
Although the terms accreditation and certification are
often used interchangeably, ACCREDITATION USUALLY APPLIES ONLY TO ORGANIZATIONS, while certification may apply to individuals, as well as to organizations. Examples of Accreditation Agencies The joint commission accredits the following types of healthcare organizations:
Hospitals healthcare networks (managed care plans, preferred
provider organizations' integrated delivery networks, and managed behavioral health)'.
Home healthcare organizations (home health, hospice, home
infusion' durable medical equipment, personal care, and support), nursing homes and other long-term care facilities assisted living facilities, behavioral healthcare organizations, ambulatory care providers, and clinical laboratories. Examples of Accreditation Agencies URAC. Formerly known as the utilization review accreditation commission, Det norske veritus (DNV), National committee for quality assurance (NCQA) Accreditation or certification standards for specific programs (e.g. Disease management or care management, and certain functions, such as credentialing). The Value of Accreditation
Improve the quality of health care by establishing optimal
achievement goals in meeting standards for health care organizations Stimulate and improve the integration and management of health services Staff effectiveness. Accreditation was cited as contributing to the effectiveness of organizations' staff in the following ways: strengthening interdisciplinary team effectiveness; Establish a comparative database of health care organizations able to meet selected structure, process, and outcome standards or criteria Reduce health care costs by focusing on increased efficiency and effectiveness of services The major purposes of accreditation Provide education and consultation to health care organizations, managers, and health professionals on quality improvement strategies and “best practices” in health care Strengthen the public’s confidence in the quality of health care, and Reduce risks associated with injury and infections for patients and staff External credibility, Organizational learning. Accreditation was cited as promoting capacity building, professional development, and organizational learning. Motivations To Participate In Accreditation Programs
Motivations to participate in accreditation include:.
True commitment to improvement in quality of patient care and services . Willingness to be held accountable/to be compared to like organizations. Enhancing confidence of the public/consumers. Condition of payment Requirement for contracting to provide services and receive reimbursement Requirement for residency programs in academic medical centers DEEMED STATUS For a healthcare organization to participate in and receive payment from the CMS or Healthcare Insurance Marketplace programs, it must be certified as complying with the standards, called CONDITIONS OF PARTICIPATION This certification is usually based on an onsite survey conducted by A STATE AGENCY on behalf of CMS or the CMS regional office. However, if a national accrediting organization enforces standards meeting the federal Conditions of Participation, CMS MAY GRANT THE ORGANIZATION "DEEMING" AUTHORITY TO CONDUCT THESE TYPES OF SURVEYS and "deem" each subsequently accredited health care organization as meeting the CMS certification requirements DEEMED STATUS CMS retains the authority to conduct random validation surveys and complaint investigations for certified organizations. CMS has planned for 5% of the hospitals and organizations that receive federal reimbursement for healthcare will still require validation by CMS after an onsite accreditation survey by a deemed agency. This number has increased since 2014 The regulations provide a mechanism by which accrediting agencies may apply to become authorized to confer deemed status. The accrediting agencies release survey information to CMS after each survey if deemed status is granted. CMS may release information from accreditation surveys if applicable to an enforcement action; otherwise, CMS keeps survey reports confidential. Compliance With Standards
Standards in healthcare accreditation have become or are
becoming more practical in the sense of:
Assessing actual performance ("performance-based") rather than
capacity to perform;.
Focusing on:- Processes and outcomes, not simply structure;
Patient care issues related to quality and safety;-
The organization's efforts to manage patient care and to support
process improvements that result in good patient outcomes. Compliance With Standards
Most agencies will accredit an organization if it is in
"substantial" or "full" compliance (expectations met) with the standards overall, even if not with each individual standard. The better an organization meets the performance measure expectation compared to peer organizations, the higher the rating for that portion of the process. Achieving compliance with the accreditation/regulatory standards and then maintaining survey readiness is the goal for healthcare organizations. Assessment Of Compliance
Most accreditation agencies use one or more of the
following means to assess compliance with applicable standards:
Review of documents that demonstrate compliance;
Onsite observations by surveyors;.
Verbal information gained by surveyors through interviews;
Examples of standards implementation;.
Review of medical/health records;.
Assessment of service/support systems;
Integration of performance measure data in scoring
Assessment Of Compliance
If a SURVEYOR FINDS ANY CONDITION EXISTING
THAT POSES A THREAT TO PUBLIC OR PATIENT HEALTH OR SAFETY, the surveyor may notify the chief executive officer of the organization and recommend denial of accreditation.
Any recommendation of denial is reviewed by the accrediting
agency before a final decision is made.
The organization is offered an opportunity to discuss areas of
noncompliance, to submit documentation to demonstrate compliance or progress, and, with some accrediting agencies, to request a face-to-face interview or even a "validation" resurvey. Accreditation Survey Readiness Preparedness/Continuous Readiness The individuals who are coordinating the effort must be very Familiar With The Regulatory Requirements and elements of performance. Deemed accrediting agencies make available the Standards And Rationale To Organizations That Choose This Method. Online and paper handbooks are available for purchase. The CMS regulations are online for download. There are seminars and educational meetings conducted by various organizations. Read the guidelines very carefully and look for time related words such as Annual, months, and minutes. The organization is either in compliance or out of compliance. For example, the joint commission has a regulation in the comprehensive stroke regulations stipulating the time in minutes to get a patient from the helipad to the emergency . Preparedness/Continuous Readiness
Most accreditation agencies use one or more of
the following means to assess compliance with applicable standards: Accreditation/Regulatory Readiness Team Review of documents demonstrating compliance Onsite observations by surveyors Verbal information gained by surveyors through interviews Examples of standards implementation Review of medical/health records Assessment of service/support systems Integration of performance measure data into scoring Accreditation/Regulatory Readiness Team
Each organization should have an Accreditation/ Regulatory
Readiness Team or committee that has created a survey preparedness plan This group is responsible for the implementation and improvement of processes in terms of existing and new accreditation and regulatory standards. This team most often consists of Key Leaders And Managers who coordinate and oversee continuous readiness and survey planning efforts. The Team Members Must Have Decision-making Authority in the organization The Quality Council, the administrative council, or a senior leadership survey team that includes key QM/PI leaders and sponsors/champions may assume the role. Accreditation/Regulatory Readiness Team Routine meetings are set to review Environmental Rounds, to establish a method of inspecting and following patients and processes through the care settings , to communicate accrediting agency and regulatory information, and to plan for dissemination of information. For example, in 2014 The Joint Commission (TJC) issued a New Patient Safety Goal Regarding The Use Of Monitors With Alarms. TJC has given organizations two years to implement this patient safety goal before they will begin to survey it in January 2016.' Specific senior leaders (president, vice presidents, chief nursing officer, administrative directors) should be designated to ensure compliance with the standards applicable to the areas for which they are responsible. In provider organizations, these leaders participate in regularly scheduled (announced or unannounced) environmental rounds. Accreditation/Regulatory Readiness Team Activities/Process Improvements Establish ongoing interdisciplinary teams Structure: Approximately three-five members Each Team Meets Routinely, Such As Quarterly, To Review Compliance with the appropriate standards/regulations, improvements, and policies. The team members conduct patient and organizational TRACERS to identify areas of weakness or areas for improvement related to the standards. The team leaders and members are well versed in the pertinent standards, operational policies, procedures, and practices and are able to identify compliance deficiencies. System problems found during environmental rounds, tracer activities (patient or process), or data tracking that are linked to standards should be followed up by the leader responsible for compliance. Accreditation/Regulatory Readiness Team Activities/Process Improvements The administrative team (leadership) is the most effective in performing periodic walk-around inspections of all settings, departments, and services, focusing on selected standards each time. Provide a grid or log sheet that outlines, for each standard, where/in what form appropriate documentation may be found to prove compliance. This log will serve the administrative and clinical teams, but also will provide support to each person participating in the survey. System changes often require the work of a quality improvement team over time A GOOD ALTERNATIVE OR ADDITION TO THE WALK- AROUND IS TO ESTABLISH INTERVIEW/FOCUS GROUPS for each important function or category of standards and each organization-wide required review process. Accreditation/Regulatory Readiness Team Activities/Process Improvements Types of team activities: Track tracer, mock survey, or other self-assessment results with appropriate software to look for trends, quick-fixes, system issues Track the findings (teams, committees, departments ) from specific performance measurement activities Intervention: If it is planned to have an outside pre-survey performed, schedule it to allow time possible for implementation of recommendations Review the QM/QI/PI processes, Be certain that the organizationwide QM/QI/PI approach is understood Learning the Regulations Once the team members have been identified, the initial steps involve compiling a listing of the requirements and then performing A GAP ANALYSIS (SELF-ASSESSMENT) to clarify what is in place and what has yet to be compiled or developed. Next, assign people to help fill the gaps. Handling Of The Documents Electronically Or Paper Work has also been successful External surveyors appreciate receiving information in a succinct and organized manner. Your organization's ability to achieve this will set the tone for success for the whole survey process. All through the preparation process, it is wise to build in Educational Opportunities With Leaders, Managers, Physicians, Staff Members, And Patients when possible. Maximize those teachable moments that occur. Presenting the material in a variety of ways also helps the learners retain the information and makes it more interesting. Learning the Regulations If it is planned to have an outside agency conduct a mock survey, it should be Scheduled To Allow The Maximum Time Possible For Implementation Of Their Recommendations. As much as possible, the mock survey should incorporate all standards that will be in effect at the time of the actual survey. However, most organizations do not need to hire a consultant or other group to perform the mock survey. Different Departments In The Organization Could Survey Other Departments. It is important to note that staff should not survey their own department, as a "new set of eyes" will see what the staff would miss. If the organization is part of a larger healthcare system, then like facilities in the system could be utilized to survey another facility. Document Preparation There are some specific documents that surveyors will want to see during the visit. The accreditation and regulatory agencies typically provide Survey Activity Guides listing the specific documents. These will need to be collected prior to the survey. Some healthcare entities organize their documents in an annually updated file box or notebook binder categorized with labeled dividers. Either way, the goal is to be able to present the documents in an organized and timely manner. It is a good practice to have two identical boxes or binders It is a good practice to have Two Identical Boxes Or Binders - one to give to the surveyor for review and the other one to keep In The Command Center so that the organization survey team sees exactly what the surveyor has been given to review. Review of the document box or binder prior to the survey by a senior leader, manager, or risk manager is necessary to prevent outdated or potentially inappropriate materials from seeping into the document compilation. Tracers A tracer is A Record Used To Assess The Movement Of A Patient Through The Health System. From entry to discharge the record is reviewed for completeness, individualized care planning, pain assessments, individualized education, patient involvement in goal setting, communication with the care team, discharge planning, and other components pertinent to the patient. For a patient who entered via the Emergency Department, a tracer might include assessing the time it took to be seen by a physician, how long it took to be admitted, and anything else that might have delayed their care Tracers examining system processes such as medication use and information flow will also occur during the survey process. When conducting mock surveys and tracers, use fresh eyes to look at your organization as if you had never seen it before. Put yourself in the place of the surveyor. Education of Staff, Leaders, and Practitioners When making rounds and conducting tracers ask staff to 'show you' that, so they know the answers. For example, staff frequently will answer a question about a resource saying that they can find it on the computer; but when put to the test, they cannot actually find it. Slide presentations are particularly helpful to teach regulatory compliance Information. Presenting regulatory compliance information via printed materials allows the reader to refer back to the document. Newsletters on the subject are available via many sources. Many Other Educational Media are available or can be developed by the organization. While email is used frequently to send out updates, there is no guarantee that the emails are even opened. The organization's electronic education system is a wonderful means of conveying information if the system is used. Crossword puzzles, fill in the blank games, and scrabble puzzles are easy to make or can be purchased from multiple sources. organization chose a Wizard of theme. As the team members were talking with staff throughout the organization, they would ask the staff questions. If the staff member got the correct answer, or could find the correct information in their department/unit, they were awarded with a sticker. The sticker was placed on a card with a Yellow Brick Road on it Knowledge Readiness Distribute the current Standards and Guidelines (NCQA), with any other appropriate explanatory material [for The Joint Commission, use the "Applicability of the Standards" matrices Review the previous two full survey reports and any interim random survey reports Review any focused survey reports and any written progress reports submitted subsequent to corrective action plans. Annually identify any changes in standards and evaluate need for associated change in organization policy Annually identify any changes in survey process, such as how the increased emphasis on patient safety Knowledge Readiness Review current organizational concerns, data, etc. to compare current compliance with the past and to identify any new compliance issues, including annually revised National Patient Safety Goals Review the current status of all quality management/performance improvement activities Remain current on patient safety issues-standards, national reporting requirements, National Patient Safety Goals Remain current on compliance with organization ethics and anti- fraud policies. Review minutes and other records of teams and committees, Review the organization's last quality management/performance improvement program evaluation report. Review the current year's quality management/quality improvement plan, objectives, and any Strategic Quality Initiatives. Review and revise all policies and procedures associated with the standards Communication Review all QM/QI/PI communication, reporting, and feedback processes and improve as appropriate Is each staff member, clinician, and governing body member able to identify at least one strategic initiative and one successful improvement within the last six months? Is each staff member able to identify the patient safety practices for which he/she is responsible? Consider organizationwide information/ communication improvements that make readiness/compliance easier Provide reminders concerning key (or problematic) compliance issues via email, screen savers, flyers, newsletters, Regulatory Compliance Leaders Meetings Conducting ongoing monthly or bi-monthly regulatory compliance meetings keeps the regulatory emphasis in the forefront with department leaders as well as senior leadership. This approach provides another layer of staff involvement in the survey preparation process. During the meetings, section leaders provide a short presentation for the group on a particularly challenging or troublesome regulation and lead a discussion on how to approach adherence to the requirement. The results of the above listed activities can also be discussed at these meetings. Preparations for the Days of Survey
Who is on the core survey team?
Compile the requested documents. Who is to be contacted when the surveyors arrive? Compile a list with cell phone numbers, pagers, etc. Where will the command center be located? Where will the surveyor's home room be located? There must be computer access in this room, and assure that the door can be locked for security purposes. Who will tour with the surveyor? Preparations for the Days of Survey
Who will scribe and take notes during the survey?
Who will be readily available in the command center? What supplies will be needed in the command center? Consider having a rolling computer case outfitted ahead of time with office supplies, laptop, power cord, flip chart markers, self-adhesive flip chart pages, organization directory, etc. For the governing board and members of expected interviews, prepare example proceedings such as questions and answers. Running practice interviews ahead of time is recommended SURVEY PROCESS
The actual survey process will vary with different
accreditation agencies, but many of the activities are similar. Surveys for all accreditation agencies with deemed statuses are unannounced, which is becoming the industry standard. The number of surveyors is determined by the accrediting organization, with consideration of facility's size, types of patients, and services provided. Most surveys are conducted at least once every three years, but this is not the standard for all types of healthcare organizations and accrediting bodies. Information unique to each type of accreditation program can be found on their websites. Surveyor Arrival Any overseeing agency can visit an organization at any time. Any day of the week may be a survey day, even on the weekends, unless otherwise stated by the agency. A surveyor might visit at any time of day, even during the night shift. When it becomes known that the surveyor is on site or on the way, it is important to immediately begin notifying the key members of the survey team and activate the survey plan. Surveyors may enter an organization via any entrance. Sometimes they are easy to spot as they will be in business dress with rolling computer cases wearing lanyards with identification. Ideally, staff at information desks are prepared to greet surveyors. The surveyors should be asked to have a seat while the administration or designated individual is notified Surveyor Arrival At the time of arrival, there should be an announcement to the organization such as, "We would like to welcome {accreditation/regulatory agency name} to our facility for their {# of days or type of} survey." This alerts all the staff and practitioners that there are surveyors in the building. This should be done for any type of survey/surveyor who is in your building, not just for the major accreditation surveys. If the organization chooses not to make the overhead announcement, then the staff and physicians need to be alerted, by some means, that surveyors are in house. Everyone needs to be on his or her best behavior during a survey, but patient safety processes need to be hard wired into their everyday practice. Entrance Interview The surveyor or team will usually want to sit down for a few minutes with the organization's designated individuals, to go over why they are at the organization (triennial survey, complaint survey, revisit, disease specific certification, initial survey, etc.) and what the schedule of the day will be. It is very helpful for the surveyor to have an attendance list with the names and titles of the attendees so he/she can refer back to it throughout the survey. The surveyor leads this meeting but usually allows questions from the group. This meeting is efficient, lasting 15 to 45 minutes, as the surveyor will want to begin the survey process as soon as possible. A typical schedule for the day at an acute care hospital might include visiting clinical units, observing medication administration, watching a time-out in surgery, assessing moderate sedation, reviewing prepared documents, visiting an outpatient care area, and touring the Emergency Department. Entrance Interview If the survey team is from a state agency or CMS, the expectation is that they should not be allowed to move through the facility without being accompanied by a staff member. There should be a designated escort for each surveyor to guide them through the facility. Deemed agency surveyors and other accreditors may prefer that their surveyors not be accompanied, but the organization has the right to assign someone as a guide. Ensure the survey team members have a private area for their computer set up and document review. Provision of information on the closest restrooms and exit doors is essential Regardless of the oversight entity, patient care should not be interrupted or unduly affected by the survey. Surveyor Work Room Escort the survey team to their home room for the duration of the survey. The ideal room for a survey team should be locked (to keep their items safe and protect the confidentiality of their notes), and contains: a telephone, the ability to connect to the internet, a printer connection, and a table large enough to accommodate several people. Some surveyors prefer to have an empty folder with their name on it for them to use during the survey. Some healthcare organizations make it a practice to provide a few basic office supplies and Kleenex in the home room. If only one surveyor is in-house, a smaller empty office can be used. It is a nice touch to provide creature comforts such as coffee, ice water, and light refreshments. Keep in mind that CMS employees may not be able to accept food unless it is being provided for the staff as well. Command Center There should be a command center established for the organization's accreditation/regulatory leaders, similar to that utilized during a disaster. Bring the rolling computer case with supplies into the room. Be sure that the command center staff has access to the regulations either online or in hard copy. Get the document box or binder that houses the prepared survey documents. One or two people are usually enough to staff the command center. If the surveyor asks for a form, policy, or procedure, the scribe with the surveyor should contact the command center to obtain the requested information. This will prevent the surveyor from getting duplicate information. Staff Interviews with the Surveyor There should be a scribe with the surveyor to note the surveyor's questions, what policies/forms are looked at, areas surveyed, staff and physicians spoken to, and which patient records are reviewed. In virtually every survey staff members will be involved in talking with surveyors. The surveyor will ask caregivers specific questions to assess their care provided, practices, communication, and adherence to policies. Staff members may ask a surveyor to re-state a question if they do not understand what the surveyor is asking. Most surveyors are very happy to clarify what they are asking for and try very hard to put staff members at ease during interviews Patient Interviews with the Surveyor
Another valuable source of information for
surveyors comes from the patients and their families. Who better to interview than someone who is experiencing the care first hand? Because of personal healthcare information confidentiality, the surveyor will ask permission to speak to the patient. Topics that are bound to come up during the interview include pain control, communication, medication reconciliation, and individualized education. End of the Survey Day It is typical for the survey team to hold a debriefing meeting at the end of each day or at the beginning of the next day to discuss how the survey is going. Managers and others should then be informed of what was found and what was troublesome to the surveyor. This will allow the staff to be more prepared and obtain needed information for the next day In some organizations, a senior leader will send a summary email communication to selected members of the leadership team at the end of each survey day. This keeps the leadership apprised of the daily findings, helps educate, and provides a means of support and encouragement for the team. Stress levels are naturally high during the survey process and this is one way to alleviate some of that stress and connect with one another. At the End of the Survey When the survey has been completed, the surveyor or survey team will hold an exit conference with the organization's leadership team to review preliminary findings. The CEO is typically asked who he/she wants at the exit conference. The official findings and citations will be provided in a written report from the surveying agency in approximately 10 days. After the exit conference is over and the surveyors leave, a summary of the preliminary findings should be communicated as appropriate throughout the facility. It is common for a senior leader to send out a summary email to selected members of the leadership team. Regardless of the results, the organization should celebrate. If there is still more to be done, celebrate the work done so far, then in the next few days continue the journey to accreditation or regulatory compliance. After the Surveyors Leave For a CMS or state survey, the organization receives a Statement of Deficiencies also known as a 2567 form. The organization then completes a detailed corrective action plan identifying the changes that will be made, who is responsible for oversight, timelines, monitoring of the performance, and reporting structure within the organization. There is a tight timeframe for response associated with citations. The time varies with the accreditation/regulatory agency, however. Usually there is a set number of calendar days specified, in which the organization must submit action plans. Do not miss submission dates. Common Correction Plan Questions to Answer What was the main issue identified by the surveyor? What was the underlying cause of noncompliance? What specific steps will be taken to prevent this from happening in the future? Who is the senior leader responsible to monitor that the action plan is completed? What timeframe is being established? What data will be collected to assess compliance? Common Correction Plan Questions to Answer What are the data numerator and denominator definitions? What are the inclusion and exclusion criteria? What is the % goal for performance? Will a sample be monitored or will there be 100% monitoring? If a sample is used, how will the sample be chosen? How will progress toward compliance be monitored? Are progress reports going to be made to organizational committees or leaders? What steps are in place to ensure sustainability of improvements? Continuous Improvement and Sustainability Identifying the root causes of a process failure, implementing changes, and monitoring the success of those interventions necessitates the use of an ongoing and structured performance improvement model (e.g., plan, do, check, and act). Making changes can be done quickly in some instances, but maintaining performance improvement is more challenging. It would be a shame to develop a process that leads to desired outcomes, then to later slide back into old inferior patterns and habits that caused the underlying problems in the first place, Being able to sustain improvements is imperative. Disease Specific Certification Becoming certified as a disease specific provider is very popular and can do much to enhance a healthcare organizations' reputation in the community. Several agencies, as described below, offer certifications including in areas such as stroke, acute myocardial infarction, heart failure, hip/knee replacements, vascular disease, dialysis, and many more. Also, some state agencies offer certifications in stroke care and ST-elevated myocardial infarction care. Specific information on the certification standards can be found on the appropriate certification agency's website Hospital Accreditation Organizations with Deemed Status At the time of this writing these four (4) CMS approved hospital accreditation organizations can provide deemed status. They are : 1. The Joint Commission (TJC) 2. Det Norske Veritas Healthcare (DNV Healthcare) 3. American Osteopathic Association/Healthcare Facilities Accreditation Program (AOA/HFAP) 4. Center for Improvement in Healthcare Quality (CIHQ) Standards are developed based on evidence for practice, expert opinion and consensus, or research.
Standards are published and reviewed and revised
periodically in order to stay current with the state-of- the-art thinking about health care quality, advances in technology and treatments, and changes in health policy. Standards may focus on the infrastructure of the organization, the processes of care delivery, or the outcomes of the care delivery system https://www.youtube.com/watch?v=uQ-Vns6X-Fc https://www.youtube.com/watch?v=OlhE8JXDnsk https://www.youtube.com/watch?v=bZ5ccp82YMA https://www.youtube.com/watch?v=t6mr3gxXx64 https://www.youtube.com/watch?v=8FWgMT-GETc https://www.youtube.com/watch?v=8FWgMT-GETc https://www.youtube.com/watch?v=xCNCbUy4hBo https://www.youtube.com/watch?v=K6Ah8ojVPiQ https://www.youtube.com/watch?v=5MqWox5U9I0 https://www.youtube.com/watch?v=DbGlwoQ53Gc