Presentazione sul tema: "Monaghan Community Mental Health Team"— Transcript della presentazione:
1Monaghan Community Mental Health Team Modello Monaghan Un servizio di salute mentale comunitaria in una comunità ruraleMargaret FlemingClinical CoordinatorMonaghan Community Mental Health Team
2SERVIZI DI SALUTE MENTALE CAVAN MONAGHAN POPOLAZIONETOTAL SQ. KM.3.300TASSO DEPRIVAZIONE SOCIALECAVAN 10.7%MONAGHAN 4.7%BUGET EUROPRO CAPITE 165 EUROCavan and Monaghan seen here in red have a combined population of 109,000 and lie on the border of Northern Ireland and covers an area of 3,300 sq. km.The Small Area Health Research Unit deprivation index shows thatIn Cavan 10.7% of the population are living in deprived district electoral divisionsCompared with 4.7% of the population in MonaghanDependency ratio is higher than the National average whilst unemployment is slightly lower. Because it is a rural area the main employment areas are argicultural and small indiginous industries such as furniture manfacturing. Our buget is 18.5 million Euro and that translates to approx 165 Euro per capita.There are a total of 55 General Practioners covering the both counties 33 in Co. Cavan and 25 G.P.’s in Co. Monaghan.
3Monaghan Carrickmacross Cavan Bailieborough TyroneArmaghFermanaghMonaghanCarrickmacrossCavanLeitrimWhat we have is total population of 109,000 approximately. Total square Km is At the furthest points it is 70 miles from east to west and 60 miles north to south.In Cavan 10.7% of the population in Cavan live in deprived areas compared to 4.7% of the population of Monaghan.The resources available to us prior to the changes were four resource centres and two acute units, one in Cavan and one in Monaghan7 Assessment Beds Elderly 4 occupied (average) Day HospitalCMX 14 places 12 occupiedW beds avg 4 occupiedBailieboro accessingResource centre SCH 24Industrial Therapy 15 places avgBailieborough
4FATTORI E INFLUENZE SOCIO-DEMOGRAFICHE POSITIVIComunità ruraleComunità coesaFamiglia non mononucleareed estesaCultura unicaBasso indice di tossicodipendenzaBasso indice di homelessnessIntegrazioneNEGATIVIArea di competenza molto estesaIsolamento ruraleIsolamento socialeBassa densità demograficaPoche infrastruttureCollocazione dei serviziTeam di lavoroAs you can see from the slide there are positives and negatives to a rural area. More recently we are beginning to see an increase in people from the all over Europe coming to work in Ireland IT USE TO BE THE OTHER WAY ABOUT in particular from the new succession countries such as Lithiuina Lativia etc as well as our refugee and aslyum seekers population which are posing new challenges for us such language barriers and lack of interpreteers our inexperience of cultural differences. However we are great believers in the statement of Socrates “ WISE MAN KNOWS THAT HE KNOWS NOTHING” ANCORA IMPARO I AM STILL LEARNING
5INDAGINE SUL SERVIZIOCoinvolgimento dei servizi in caso di non adesione al trattamento:quale operatività in un innovativo modello nel campo della salute mentaleAnalisi del ruolo del medico di medicina generale referenteFenomeno“whirling door” : studio su un gruppo di persone con frequenti riammissioniSoggetti che sfuggono all’attenzione dei servizi psichiatriciUn’analisi sulle persone lungoassistiteCittadini che afferiscono all’ospedale psichiatricoVerso la chiusura dell’ospedale psichiatrico: uno studio sulle persone ancora ospitiFollow-up a lungo termine su persone dimesse con importante patologia psichiatricaCaratteristiche della presa in carico giornaliera a lungo termine in un servizio di salute mentale rurale irlandeseValutazione dei bisogni di persone lungo assistite che vivono nella comunitàA service research programme undertaken by the Cavan/ Monaghan Mental Health service showed the following results. We had a high certification rate running between 61.5 and 86.5 per 100,000 of the population. While these rates were equivalent to national rates they were much higher than rates in neighbouring jurisdictions eg The U.K.
6RISULTATI DELLA RICERCA 59% della popolazione risultava in carico48% di questi frequentavano i servizi30% veniva visto entro una settimana36% veniva visto entro 4 settimane6% necessitava di cure per 1giorno40% necessitava di cure per 7 gg54% necesitava di cure per più di 7 gg57% aveva avuto almeno un contatto17% aveva 5 o più contattiOf equal concern were the findings that 59% of certified patients were currently attending either their GP or the mental helath service with 48% of these attending the mental health service. Of those 48% attending 30% HAD BEEN SEEN WITHIN 1 WEEK AND 36% had been seen within 4 weeks of certification. With 40% been unwell for 1 week and 54% unwell for more than a week.66% of people had dropped out of outpatient care by the 4th visit.Our research also showed that 4.6% of patients accounted for 23.6% of admissions and 18.3% of occupied bed days.
7Risultati della ricerca Mancanza di input su utenti dei servizi e sui carersInadeguata focalizzazione sul pazienteAncora troppi esclusi dalle cure psichiatriche di baseEccessivo ricorso alle terapie farmacologicheServizi basati sull’ospitalità notturnaConcezione insufficente dell’ approccio (cura) comunitarioGruppi multidisciplinari ristrettiProblemi nella gestione dei serviziPiano nazionale dei servizi obsoletoServizio pubblicoCarenze della formazione e dello sviluppo professionaleOrganizzazine clinica in via di sviluppoA picture begins to emerge of a service thatFails to recognise and address individual problems of people involved.A service limited in its ability to respond to acute relapse in ways other than certification.The need to phase out institutional beds and establish appropriate alternative facilities in the communityThe necessity for ungoing individulalised care programmesThe importance of multtidisciplinary approache in assessing and meeting the needs of service users.The need for a much closer relationship between psychiatric and primary care services with protocols govering referral practiceThe need to proactively manage outpatient activityThe need for partnership working with other statutory and non-statutory agencies.It was a task orientated service rather than a people orientated service.The aggregate of the research described a service that continued to base its treatment responses on traditional structures and practicies which were inefficient, ineffective, and not meeting peoples needs.We recognised the breadth and diversity of the needs of service users which required an whole systems approach that would facilitate recovery in all areas of people’s lives.What was operating was a bio medical model which is a closed system approach. Closed systems are very rigid and are based on dualistic thinking for example the right way and the wrong way. In healthcare this dualistic thinking has created the expert (the professional and the pateint.) Closed systems are not collaborative, they do not interact with the wider context. They are set and predetermined and in this system do not take the service users needs into consideration. The Expert determines.What we needed to do was to shift from a closed systems approach which is a medical model to an open systems approach (biopsychosocial model) which is based on collaboration, partnerships and teamworking to build networks of knowledge, people and agencies in order to provide an all inclusive untied mental health system that is person centred, needs led, family supporting, recovery orientated,clinically compented and flexible. and which was founded on the following principles.Centrality of service user / recipients needs and rightsDelivery of individual effective treatment packages in the setting of home, family and communityEmpowerment participation partnership and citizenshipMental health is a community issue. A community resource based model has at its foundationhousing, work, education, income, and other basic elements of citizenship. Rights to:Equality of opportunity.Economic security.Justice and respect.Freedom of speech.Freedom of choice.To be an individual.Self-determination.described a service, which continued to base it’s treatment responses on traditional structures and practices that were inefficient, ineffective and not meeting peoples needs.We recognised the breadth and diversity of the needs of service users which required an whole systems approach that would facilitate recovery in all areas of people’s lives. We shifted from a closed systems approach which is a medical model to an open systems approach (biopsychosocial model) which was based on collaboration, partnerships and teamworking to build networks of knowledge, people and agencies in order to provide an all inclusive untied mental health system that was needs led and which was founded on the following principles.
8Organizzazione precedente al 1998 AGENTI DI RIFERIMENTOPSICHIATRI CONSULENTITERAPIA OCCUPAZIONALECONSULENZA PER LE TOSSICODIPENDENZETERAPIA FAMILIARETER. COMPORTAMENTALEASSISTENTI SOCIALIINFERMIERI/CPNThis is are referral pathway prior to regorganisation 1998?There were multiple access points into the mental health service where disciplines worked autonomously and in isolation. We can begin to imagine a service that is covering 2 counties 3,300 sq.km serving a population of 109,000 with 55 general practioners. Chaos comes to mind.PSICOLOGIAGENTI DI RIFERIMENTO
9STILE DI LEADERSHIP E MANAGEMENT ORIZZONTALEGRUPPO DEI PARI, COLLETTIVO, COLLABORATIVO, COMUNICATIVO (OPERATIVO)PIANIFICAZIONE CONDIVISA, RESPONSABILITA’ CONTABILE E DI RISULTATOPROCESSO DECISIONALE FLESSIBILE, AUTONOMO, COMPETENTE.MOTIVAZIONE, INNOVAZIONE, CREATIVITA’, DISPONIBILITA’ AI CAMBIAMENTI, SODDISFAZIONE DEL LAVORO, DOMANDE RIDOTTE SUL TEMPO DI GESTIONE
10STILE DI LEADERSHIP E MANAGEMENT Carta dei dirittiStile tradizionaleSupervisione top down (piramidale)Autonomia decisionaleFiducia nel ruolo, competenza specifica ben definita
11Il cambiamento Evoluzione Innovazioni creative Miglioramento continuo Pensare a sistemi apertiPratiche basate sull’evidenza (scientifica)Management creativo improntato al cambiamentoResistenzaGestione sicuraControllo di qualitàProcedura di sistema ben definitaPratiche abitualiAmministrazione burocraticaContinuous improvement – continually challenging or questionning your standards to ensure that they are meeting changing need.Quality control – meeting a pre determined defined standard.Like any living organism mental health systems either evolve or die. There is always a tension between conserving the status quo and change. To conserve the status quo, there is a reliance on fixed policies, traditional ways of doing things and ideas that have proved successful in the past. On the other side there is a need to adapt to change in conditions, changing needs, new ideas (top down legislation, commission of nursing, informed service users and carers, educated society, evidence based practice). Systems do not endure by rigidly resisting change, but by weaving change into the fabric of the organisation so that the organisation is always adapting and growing. It was important that we questioned our current assumptions and procedures, there was no recipe for developing new mental health systems. Ingredients may be put together differently in different places, according to resources and demography.
12UN RI-ORIENTAMENTO RADICALE DEI SERVIZI PER INDIRIZZARE TALI QUESTIONI NESSUN FINANZIAMENTO EXTRAThere was absolutely about it things needed to change we needed a fundamental regorganisation and redesign of service delivery and in the absence of any central planning and without additional funding. We went for a bottom-up approache. This strategic shift in the service was to includeFlexibility in responses to service users needs and preferencesA more community based service with closer links to primary careAlternatives to hospitalisation
13ANALISI SWOT PUNTI DI FORZA OPPORTUNITA’ PUNTI DI DEBOLEZZA Timori Staff (non gruppi)OPPORTUNITA’Esperienza passataEvidence based practiceConvenzionePUNTI DI DEBOLEZZAInflessibilità, passivitàDirezione medica / “lettocentrismo”“Ospedalocentrismo”Conseguenze dei ricoveri / certificazioniMancanza diCoordinamento / ComunicazioneSottoutilizzo del personaleTimoriCambiamentoResistenzaFallimentoProfessionismoTerritorialitàWe carried out a SWOT anlysis our greatest strength as in any other healthcare system was our staff highly skilled talented and knowledgable. A magician can only pull a rabbit out of a hat if there is already a rabbit in it. Our rabbit was our staff. We had past experience of change We were successful back in the 70,s when we began to move people out of the hospital back to the community. There was a strong research culture and an openess and awarness of new ideas and of evidence based practice such as the work of of Dr. John Hoult, Lein Stein, Allen Rossen to name but a few.Our weaknesses as you can see were that we were structure centred rather than person centred medically tasked and bed orientated, problem focused, concerned with symptomatology, diagnosis with an over emphasis on medicationclinical decions were been influenced by bed availability The research had clearly indicated thet we were passive and that people had to fit into existing services rather than the service meeting the individual needs of service users needs.The multiple access points lead to poor coordination and fragmented communication.The majority of staff were hospital based while the majority of service users were in the community this was a gross under utilisation of staffThe threats of course are the same threats you will get in any organisation. It is difficult for people to change especially when they have invested years learning how to operate under a traditional system and therefore resistance should be seen normal.One of the major resistance forces to chgange is when people are not prepared to take risks there is fear of failure or disaster.However in healthcare we have the additional threat of professionalism and terroitorilism
14VISIONFornire un sistema di cura personalizzato integrato, esauriente, di alta qualità, di sostegno e che risponda ai bisogni delle personeIt is crucial when implementing change that everybody buys into it and that it is not change for the sake of change. The challenge was a mind set leap. A liberetion from traditional thinking to the creation of a new future. A vision is a dream, a hope for the future and it COMMUNICATES when it is shared and people believe in the importance of cooperation and partnership in creating that future This required a need for structures, systems and a cohesive framework to be put in place in which all disciplines could deliver a safe, effective, efficient quality service.
15PRINCIPI un Servizio Competente un Servizio con un unico punto di accesso, facilmenteraggiungibile, disponibile e sensibileun Servizio che pone al centro la priorità dei bisogni e dei diritti degli utentiun Servizio che offre un efficace pacchetto individualizzato nell’ambito della casa e della famigliaThe buliding blocks to transform a vision into a reality are principlesWe formed and agreed on 4 principles on which the service should build and they were and still are that it must be -A specialist serviceA service with a single point of access that is easily accessible, available, and responsiveA service which has at its core the primacy of service users needs and rightsA service which delivers an individualised effective treatment package in the setting of home and family
16ELEMENTO CENTRALE DELLA STRUTTURA DEL SERVIZIO GSMC per disturbi acuti e crisi con cura infermieristica a domicilioGSMC per disagio mentale di lunga durata con assistenza infermieristica specializzata prolungataGSMC per persone anziane con disagio psichico di lunga data con assistenza infermieristica domiciliareGSMC = GRUPPO SALUTE MENTALE COMUNITARIAWe opted for 3 functional teams each specialised in different areas and coordinated by a clinical coordinator. It was important that these 3 teams were well intergated1 CMHT the focus on acute mental illness and crisis which is known as the CMHT2 CMHT the focus on enduring mental distress which is known as the Community Rehabillitation Team3 CMHT the focus on mental ill health in later life which is known as Psychiatry of Later Life
17BILANCIAMENTO CAMBIAMENTO-STABILITA’ CHANGE AND STABILITY ARE POLES ON A CONTINUUM NOT OPPOSITESThe reorganisation of the service required a balance between change and stability. Neither must not outweigh the other. We needed to maintain a service whilst at the same time creating change. Communication was vital to this process it must flow openly and freely in order to create a balance it is imperative to have close and ongoing relationships with people both within the service and outside. Communication is pivitol to the change process it is not about talking to people it is about talking with people listening to their views, opinios, arguments,and affording respect for all. Regonising that change can be difficult and frustrating Comprosing and negotiating. Instilling a sense of support partnership and cooperation and ownership. Ultimately people needed a stable predictable environment in order to continue to do their work.COMUNICAZIONE
18CAMBIAMENTO CHE MANTIENE LA STABILITA’ INTERNOCOSTRUZIONE DEL GRUPPOINCONTRIGUIDA DEL SERVIZIOPOLITICHE OPERATIVE HBTT/ PORTINERIASINGOLI PUNTI D’ACCESSOGRUPPO MULTIDISCIPLINAREHBTT = health based treatment team ( gruppo per il trattamento della salute di base)ESTERNOCREARE ALLEANZAINCONTRI CON I M.M.G.RASSICURAZIONEAZIONEIn order to prevent the perception that HBT was an elitist group all disciplines were invited to a meeting where new ideas were explored, opinions were discussed, concerns were addressed. Each discipline was invited to present a formal presentation on their role and the services they provided. This ensured that each discipline understood, valued and respected each others role. It also helped in clarifying boundaries. This information was collated and presented in a published book form as a directory of services. And through discussion, agreement and consensus rules of operation were re defined and the policies for the future were agreed and we took on the name of the Monaghan Community Mental Health Team meeting the aspiration of a specialist service. A service that focussed entirely on acute mental health problems. A service that had at its core the primacy of service users needs and rights. The reorganisation of the service was founded on the following principles.Centrality of service users needs and rightsDelivery of effective treatment package in the setting of home and familyMinimum use of inpatient bedsResponsiveness empowerment participation partnership citizenship
19PARTERNARIATO NEL CAMBIAMENTO SVILUPPO DI ALLEANZE NELLA COMUNITA’INCONTRIRETE TRA AGENZIECOLLABORAZIONI COALIZIONIThe bio-psychosocial model requires a need to develop networks and interagency collaboration to obtain skills in areas that were unfamiliar to mental health professionals. We developed coalitions with external agencies inviting them to meet with the multidisciplinary team in order to outline their area of expertise within the community, building access to community resources such as accommodation, education, employment and income because mental health is not exclusive to mental health services, mental health is a community issue and has at its foundation the basic elements of citizenship i.e.. Housing, income, employment, education and rights to,Equality of opportunityEconomic securityJustice and respectFreedom of speechFreedom of choiceRight to self determinationCommunity mental health is built on partnerships with service users, families, and significant others, it is about participation, collaboration, interagency and it is about interdependence not independence.
20SETTORE SALUTE MENTALE COMUNITARIA DI MONAGHAN ABITANTI 52.772 2 psichiatri consulenti1 segretario dirigente3 amministrativi1 coordinatore clinico6 operatori ADI1 operatore territoriale di supporto3 infermieri psichiatrici di comunità1 segretario1.5 psicoterapista cognitivo comportamentale2 terapisti familiari1 terapista occupazionale1 Psicologo1 assistente sociale1 consulente alcologia2 consulenti dipendenze1 consulente per lutti1 Consulente1 terapista complementareUnità per acutiDay HospitalCentro risorsa “SOLAS”Consulente legale
21SETTORE SALUTE MENTALE COMUNITARIA DI CAVAN ABITANTI 56.416 2 Consulenti1 responsabile amministarativo3 amministrativi1 Coordinatore Clinico7 Operatori domiciliari1 Operatore territoriale di supporto1 Segretario4 Cousellors sulle dipendenze4 Infermieri esperti di comunità1 Assistente Sociale1 Terapista della Famiglia1 terapista comportamentale1 consulente esperto del lutto1.5 Terapista occupazionale1 PsicologoUnità per AcutiDay Hospital
22GRUPPO RIABILITAZIONE COMUNITARIA Catchment pop. 109,188 1 coordinatore clinico14 Operatori specializzati6 operatori territoriali di supporto1 Consulente psichiatra1 Segretario dirigente1 segretario3 Infermieri psichiatrici di Comunità3 Infermieri per la continuità terapeutica0.5 assistente sociale1 Terapista comportamentale4 +1 strutture protette(50 posti 45 occupati+16 letti nella nuova sede)12 Gruppi appartamento55 Posti 38 occupati1 Segretario
23PSICHIATRIA DELLA TERZA ETA’ Catchment pop. 109,188 1Coordinatore1Consulente psichiatra1 segretario dirigente1segretario8 infermieri domciliari3 operatori di supporto1 terapista comportamentale2 Segretari1 Assistente SocialeUnità di valutazione7 posti lettoDay Hospital10 accessi 2 operatoriTerapia complementareResearch in the British Journal of Psychiatry – 513 idenitifes that there is an astonishing variety of how community mental health teams are implemented at least in the UK They identify 7 types of community mental health team models. For example, generic multidisciplinary mental health teams, generic community mental health teams suplemented by crisis home based treatment teams, etc. Mueser et al 1998 in an overview suggests that regardless of the configuration of community mental health teams most studies show that community mental health teams bring about a reduction in length of stay in hospital. Service users prefer community mental health teams to more traditional services.The British Journal of Psychiatry – 502: The conclusion of this study showed that community mental health team management is superior to standard care in promoting greater acceptance of treatment, may also reduce hospital admission and may avoid death by suicide. This model of care is effective and deserves encouragement.
24Monaghan Carrickmacross Cavan Bailieborough GRUPPO RIABILITAZIONE COMUNITARIA (POP. 109,000)PSICHIATRIA DELLA TERZA ETàSERVIZI PER LE DIPENDENZECommunity Mental Health TeamMonaghanThe resources available to us prior to the changes were four resource centres and two acute units, one in Cavan and one in Monaghan7 Assessment Beds Elderly 4 occupied (average) Day HospitalCMX 14 places 12 occupiedW beds avg 4 occupiedBailieboro accessingResource centre SCH 24Industrial Therapy 15 places avgCarrickmacrossCavanCommunity Mental Health TeamBailieborough
25PERCORSI DI RIFERIMENTO Our referral pathway is much more streamlined easily assessibleI will now hand you over to Bridie Mc Donald who will outline how this is actually achieved.COMMUNITY REHABILITATION TEAM
26Community Care Gardaí Acute inpatient Solas Primary care CPN S.W. AdminCPNS.W.Self HelpH.B.T.AdvocacyAddictionMedical SecretariesHousingCoordinatorFamily TherapyYouth GroupsManagementMedical TeamO.T.Where ever a group of people exist a system exists.From a whole systems thinking what we had prior to our strategic shift was a closed system which is a medical model IT IS RIGIT AND BASED ON DUALISTIC THINKING the right way and the wrong way THIS DUALISTIC THINKING HAS CREATED THE EXPERT (PROFFESSIONAL) AND THE PATIENT. Closed systems are not colloborative they do not interact with the wider context. The set pretermined and in this closed system or medical model service users are seen in terms of their diagnosis rather than as individuals and people become passive receipients of care. The biopsychosocial approache is an open system approache which is based on multiple discourse and the equality of each voice it does away with the concept that there is one way of knowinG to the concept that there are multiple ways of knowing. It focuses on the whole person and places greater emphasis on the uniquiness of the individual. It is colloborative and autonomous but remains connected. It promotes independence, personal growth, and achievement of personal potential. Where the service user is the expert and is an active participant.Research by Shepherd et al 1994 suggests that service users place greater emphasis on the social and practical aspects of life in the community. The provision of services to enable recovery requires more than a healthcare system. It requires a coordinated interdependent whole systems approach which includes multi sectoral collaborative alliances.Women’s GroupsBehavioural TherapyEmploymentEducationPsychologyVoluntary groupsHealth promotion
27Tasso per 100,000 abitanti over 16 anni 1997Cavan/MonaghanNationalAmissioni totali639.5959.8Primi accessi179.1256.8Rientri460.4703.0Tasso certificazioni53.06105.6
28Rates per 100,000 of the population over 16 years 2000Cavan/MonaghanNationalAmissioni totali297.2901.0Primi accessi104.8270.5Rientri192.4630.5Tasso certificazioni41.1397.0
29Rates per 100,000 of the population over 16 years 2001Cavan/MonaghanNationalAmissioni totali270.7907.1Primi accessi95.5270.9Rientri175.2636.2Tasso certificazioni59.799.0
30Rates per 100,000 of the population over 16 years 2002Cavan/MonaghanNationalAmissioni totali233.8781.7Primi accessi79.9233.1Rientri153.9548.6Tasso certificazioni42.989.17
31Rates per 100,000 of the population over 16 years 2003Cavan/MonaghanNationalAmissioni totali252760.4Primi accessi84.8219.8Rientri167.2540.62Tasso certificazioni60.180.4
32Research by Shepherd et al 1994 suggests that service users place greater emphasis on the social and practical aspects of life in the community. The provision of services to enable recovery requires more than a healthcare system. It requires a coordinated interdependent whole systems approach which includes multi sectoral collaborative alliances.
33MMG: responso – valutazione grado di soddisfazione Buon livello di comunicazione e relazione con lo staffComplessivamente valutato come un buon sistema e si auspica l’espansione verso i servizi per i disabiliUrgenza / crisi – affrontate con efficacia ed efficenzaServizio di grande aiuto in grado di vedere l’utenza in crisi quando contattato dal mmgMolto piacevole lavorare con il servizio, è sempre di grande supporto e disponibile a rispondere alla crisi o ai bisogni urgenti. Servizio ottimo – Comunicazione eccellente.
34MMG: responso continua…………. Accesso eccellente - Molto utile e disponibileBuona gestione dei posti letto (a volte molto difficile) – Esempio per altri servizi…Raccordo con una varietà di servizi – psichiatrici, terapia comportamentale, terapia occupazionale, psicologia, terapia familiare etc.La soddisfazione dei pazienti che possono essere seguiti sul territorio nelle loro case, presso le loro famiglie è tenuta molto in considerazione
35Evaluation using the Verona Satisfaction Scale assess satisfaction with services on a five point scale across seven dimensions.
37The response of the service to crisis or urgent needs G.P. 14% mixed 45% mostly satisfied 41% excellentCarer 7% mixed 60% mostly satisfied 26% excellentCleint 3% mixed 60% mostly satisfied 28% excellent
38The effectiveness of the service in helping patinets deal with their problems G.P. 4% mixed 73% mostly satisfied 23% excellentCarer 10% mixed 57% mostly satisfied 29% excellentCleint 3% mixed 56% mostly satisfied 40% excellent
39Go to the peopleLive among themStart with what they knowBuild on what they haveBe of the best leadersWhen their task is accomplishedTheir work is doneThe people all remarkWe have done it ourselvesTHANK YOU
40Vai tra la genteVivi tra di loroInizia con quello che sannoCostruisci su quello che hannoSii il migliore tra i leaders,Quando l’obiettivo è raggiunto,L’impresa è compiuta,Fai notare a tutti che lo abbiamo fatto insiemeGrazie