Dr. Colm Henry:

I will give a brief comparison.

All 19 units receive a suite of quality indicators, some of which are events that occur at a very low frequency. When one looks at a graph and sees an outlier, because it is a low frequency event, it is not appropriate to draw conclusions. What is appropriate is that management and clinicians investigate it to see if it reflects a quality issue, among the other explanations there could be for it. There is a degree of interpretation required, especially with low frequency events such as something that may be a claim in a particular unit.