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Doctor receipt format for Quality Assurance

okay we'll get started hello everyone good evening good afternoon good morning wherever you're joining us from thank you for joining this is perspectives at portland initiative by kiwani today we'll be talking about cost of quality in a laboratory quality is never an accident but it is always the result of high intention sincere efforts intelligent direction and skillful execution that will help us understand more about quality and the cost of it in the laboratory we have professor ashok rathan with us today professor rathan is a medical microbiologist by profession and he was comfort the apg abdul kalam award for lifetime contribution to medical sciences in 2018 and srinivas oration in 2021 by indian association of microbiologists for his contribution to laboratory diagnosis of tuberculosis at present he is an advisor in pathkyne laboratories and prior to that he has held positions in academics industrial research public health and diagnostic labs professor ratan has published over 100 peer-reviewed research papers internationally named in 30 international patents i'd over 40 doctoral and post doctoral students and authored the book antimicrobials in laboratory medicine before i turn the stage to professor ratan just a little housekeeping please stay on mute and don't raise your hands during the presentation if you have any questions in your mind during the presentation type them into the q a box into your zoom control panel and i'll bring up your questions during the dedicated qna session once the presentation is over so you can keep putting in your questions but we will bring them up towards the end once we get into the dedicated q a session now let's turn our attention to professor ashok thank you so much for joining it's a great pleasure to have you with us today i'm super eager to know what is the cost of quality in a laboratory so let's get fired away good afternoon everybody today we'll deal with understanding the cost of quality in the laboratory diagnostics play a very important role in health care they appear to influence at least 60 percent if not more of all the decisions that are taken in the hospitals the total cost of lab tests may be only three percent of the total medical costs but the lab tests influence clinical medicine in diagnosis in prognosis in predictive assessment of patients in prevention or monitoring of disease in management of treatment then they influence public health that aggregates of test results are used for disease surveillance healthcare performance measurement and quality improvement and clinical data also provides new knowledge for innovation evidence based medicine and improve clinical practice guidelines for setting up an optimal laboratory systems you require people facilities methods and equipment followed by training in standard operating procedures use of quality control and total quality management this is supported by external assessment strategic planning and remedial remedial action whenever required the diagnostic cycle consists of a person deciding the test to be done selection of tests ordering of tests sample collection transportation sample accessioning analysis reporting interpretation and back to the doctor now this can be divided into three stages the pre-analytical stage the analytical phase and the post-analytical phase but the pre-pre-analytical phase and post-post analytical phase have also been added so that now you have seven you have five phases of the diagnostic cycle for everybody is worried about providing service and service pathway of workflow is important but before you start providing service it is essential that these 12 quality system essentials are in place because these are the pillars on which the quality of service will depend without the 12 quality systems essential your lab work will be like a house on cards once you have the 12 quality systems essentially in place there will be reduction or elimination of medical error likelihood to meet the customers satisfaction potential for successful successfully meet accreditation assessment and sustained attainment of quality objectives there has been a sea change in our understanding of how to fix the problem in the past we used to feel that bad quality is because of bad apple so we would try to identify the person who makes the mistake blame him shame him and then get rid of him but daming with his red bead experiments indicated that if we take a ball which has 800 white beads and 200 red beads 800 white beads indicating the correct process while the red beads indicate process mistakes in the process and give a purse give anyone a spatula containing 50 so that it can pick up 50 beats nobody will be able to pick up only white beats that would mean that if there is mistakes in the process no matter how diligent a person is he would make mistakes medical error is a failure in process is the fundamental difference we can consider patient sample as an input laboratory process and then we get a test report so a laboratory is connects connecting all these processes together most of the errors occur in pre-analytical stage and therefore in any laboratory if a person says my responsibility is only within the laboratory then is making a big error because mistakes would occur if the sample is bad so what is the definition of quality many persons have used different definitions but overall it is what is perceived as their needs and the iso standards say degree to which a set of inherent characteristics of a product of surface fulfills requirements requirements have to be that of the customer so what is it that the customer wants whether it is business to business or business to customer the customer wants a reliable and reproducible results which are accurate and precise in clinically relevant turnaround time at reasonable price if the laboratory is not producing results that are accurate reliable interpretable and timely that laboratory is a liability in the health care system and can do much harm reliable and reproducible results would be that each time you hit the target right duran had said that the reduction in variation variation is the evil so in every every process we should try to reduce the variation variation is not there are many various influences which influence the various factors which influence the quality whether it is specimen whether it is environment the reagents the test system testing personnel and they all can contribute towards incorrect results so we need to pay attention to each one of them in the recent past the chemistry has improved so much that many of the tests can be classified as six sigma with very little variation but there are still some tests which perform at much below that level normally in a pro in our movement towards total quality management quality cost and calculating the quality cost is an important factor in that journey most of the labs clinical labs are at four sigma that would mean that they would make more than 6000 mistakes per 1 million opportunities and would use up 15 to 25 percent of their revenue in addressing these failures our attempt is to move the labs the lab process from four sigma to six sigma where there are very rare mistakes and less than one percent of revenue is lost addressing these failures what really happens is that the profit gets small as a consequence of the cost of production which also includes the cost of failure and that is the waste and if we can remove this cost of failure then we we can increase the margin of profit phil cosby said quality is free it is not a gift but it is free what costs is the unquality things that we do where we repeat tests revise results replace samples and redo the work all that cost money that we cannot charge he also said bad things happen on their own good things happen only when plant so the cost cutting mantra is to do it right the first time and every time anything else will cost more the traditional thinking is that the value that we get from any service depends upon the output and the input so the feeling is that if the if the input is low then then we would have more profit so there is also a feeling that you get what you pay for so meaning that if you want better service you have to pay more but recent research has indicated that new technologies that can reduce human failure automation has reduced human errors and delta checks and auto verification has optimized human resources time utilization thereby if we act quickly and at the right time we would decrease the amount of money spent but increase the amount of money gained in the process you have the physician ordering the test then the samples being collected from the patient the sample the correct sample being being processed after registration and then the report being ready if the if every step is checked and the the error is eliminated the cost of error reduction will decrease so the cost of quality could be divided into prevention cost appraisal cost and failure cost failure cost could be internal failure or external failure in the in the prevention cost that is is making sure that we do the right thing right every time this is the amount which is required the maximum and unfortunately is paid the least attention the second part is appraisal cost we seem to spend a lot of money in making sure that the results are right but if the mistake has occurred then the time and resources have already been utilized when we find the mistake on the other hand majority of the labs spend a lot of funds and resources to take care of failures whether internal on or external there is a 1 10 100 rule which indicates that one dollar spend in prevention is equal to ten dollars in appraisal and hundred dollars in failure the prevention costs are those associated with laboratory activities specially designed to prevent poor quality in laboratory services for occurring in the first place president john f kennedy once said the time to fix the house roof is when the sun is shining not when is raining periodic planning of quality goals and objectives work process training and competency assessment assessment of supplier capabilities validation or verification of new or changed laboratory tests and processes and quality management and improvement activities all constitute preventive costs and are essential for a functioning of a good laboratory our goal is to do the right thing right first time each time that can only occur if everything is in place before we start doing the first test we must be clear about what is preventive costs these are for laboratory activities specially designed to prevent poor quality in laboratory services for activities that prevent problems error of waste from occurring they are not cost incurred to keep a problem or error from recurring so if the if the problem has already occurred then it is not preventive cost it is it will be appraisal cost the examples of preventable laboratory cost are preventive maintenance maintaining your labs instruments and equipment ing to the manufacturer's schedule ensures reliable performance and no breakdown quality planning as the old army saying goes prior planning prevents poor performance work process training and in initial competency assessment after the persons have been trained so that they are able to perform the job well these all will be preventive cost and should be should find their place in the budget our goal is to do the right thing right first time each time remember five piece prior planning prevents poor performance coming to appraisal cost for appraisal cost is for evaluating quality of work after it has been performed it is for for measuring evaluating auditing to ensure conformance to requirements to catch and correct problems and error before harm to laboratory users of patients some of the examples are ongoing competency assessment to ensure the staff maintains competence calibration to ensure accuracy of measuring equipments inspection of samples and reagents to ensure that the quality of input that the sample is not hemolyzed is not lipic or contaminated quality controls to run controlling quality controls to ensure that testing methods are working and results are valid and proficiency testing to ensure methods performance compares to peers and external accreditations ensured lab performance to minimal standards so the examples of laboratory appraisals are this gives you the last chance to catch and correct before the report reaches the end user this will include quality assurance and this should be quality assurance program there should be a quality control plan and quality material is bought and used then we come to the failure cost failure cost is is that cost that services that do not meet quality requirements the first time you usually need a rework or correction failure cost could be internal failure cost where the mistake is caught and corrected inside the laboratory before delivery of results or reports and external failure call is that when the mistakes are detected outside the laboratory by user who receive faulty reports results or other services examples of laboratory internal failure cost are sample problems received sample do not meet acceptance criteria and need recollection especially some tests which need to be done on fasted condition or the sample has to come in frozen condition invalid instrument run when qc of calibration is out of control and results cannot be released expired reagents or material are not to be used in phlebotomy or testing anything that causes delay in turnaround time like rework retesting repair or downtime of equipment is examples of internal failure cost examples of external failure cost is customer complaint when a customer is dissatisfied reports recall because of erroneous results which are corrected and results and resulting consequences misdiagnosis cost of not receiving needed treatment and the cost of receiving treatment is honestly not including patient distress and loose lawsuits which are uncommon but very costly when for whatever reason so the expenses of rectifying quality problems internal failure costs and external failure cost should be avoided as far as possible and that is possible if you pay more attention to preventive and appraisal costs so we should look at the cost of quality has two parts cost of good quality and cost of poor quality cost of good quality means preventive cost and appraisal cost and these should definitely be budgeted in the in the budget for the lab initially itself and cost of poor quality is difficult to estimate but it includes internal failure cost and external failure cost and our aim should be minimize this because it is difficult to budget for poor quality but if the lab has poor quality then at least 25 percent of its revenue is wasted in addressing poor quality quality planning training making sure that the services requirements are established and met quality management systems and quality improvement activities are all excellent examples of preventive costs and must be budgeted in any plan appraisal cost will be competency assessment of the staff verification or checking of incoming material process set and products and quality audits must form part of appraisal cost and must be budgeted internal failure cost will is because of unnecessary work instrument downtime and inefficiencies reworks such as re-run recovering missing specimens redraws correcting data entry errors and repairing breakdown equipment and failure analysis all these will cost a lot of money to the lab and should be avoided external costs are complaints harm to the patient corrected reports and lawsuits and should be avoided so the impact would be that if the waste is removed then profit will improve and the waste and for preventive cost the qc calibrating material pt program internal audit program external accreditation assessment equipment maintenance and services computer systems and training should all be budgeted it's often said that we don't have the time to do it right and that is why things go wrong but if you look at it if you work the right way first time then you have to do only pre-examination examination and posting examination if things go wrong then along with that you would have to do discovery of failure immediate action investigation and report completion and in some cases you might have to do root cause analysis corrective action besides everything else so if you don't have the time to do it right the first time when will you have the additional time and resources to do it right subsequently so as we move from external and eliminating external and internal failures and increasing prevention we would find that the lab will become more leaned lab and errors and waste free services will be provided the waste activities identified are many in the lab waiting of in the patients doctor waiting patient waiting lab waiting for lab results transportation over processing supply management motion defects over production and misutilization of skills are all examples of waste in the lab and we should avoid this waste as far as possible we should also know that what we see is tip of the iceberg there are many other errors which if we start auditing correctly we would be able to identify and get rid of so that if we have good prevent preventive and appraisal activity going we will decrease our cost of failure internal or external but each time i'm stressing that you must budget well for prevention cost and appraisal cost most of the costs of running the lab is because that the cost of prevention is low but cost of failure is high and most of the labs have more failure cost and appraisal cost than prevention cost on the other hand if they they can identify what is the total cost of quality and cost of implementing a quality program they would find that by decreasing the failure cost and increasing the the prevention and appraisal cost you would find us an area which is which is ideal and that's where you would like to be in the end i would like to say once again as phil was cross b set quality is free it is not a gift but it is free what cost is the unquality things that we do that is repeat test revise results replace samples and redo all that cost money bad things happen on their own good things only happen when planned the cost cutting mantra that i can give you is do it right the first time every time anything else will cost you more and finally quality is never an accident it is always the result of high intention sincere effort intelligent direction and skillful execution it represents the wise choice of many alternatives quality also marks the search for an ideal after necessity has been satisfied and mere usefulness achieved your watchword should be doing the right thing right the first time every time i thank you for your attention well thank you very much uh so that was a good intro into the need for quality especially the preventive ones um there are a few questions that have already come in and um so now i'm opening up for everyone else if you want to ask any questions to professor rafin this is the time now so please use the q a box in the zoom control panel that you'll see on the bottom of your screen and raise your question so the first question uh is from shma startup the question is are there no human errors at all can every human error be attributable to processes failure no human errors will occur but our aim is to train them so if uh if you first away first attribute every error to a human error then you'll find that you're never going to improve first is to make sure that the process is is fundamentally right and even then you'll notice that the more often than not the persons will do it right there are only very few exceptions where a person has to be reprimanded and relieved most of the time the process it is it's a mistake of the management in allocation of resources or choosing of the material that have changed so if you address yourself if you do the root cause and analysis of the problem you would then be able to identify what was the basic what was the root cause of the problem and use a root cause analysis to find out the problem and fix the system okay so don't jump onto humans first look whether there's a process failure and then go to the humans to fix it yes okay some people are asking the questions in the chat window um it will be easier and in one place if you can please use the q a window ramesh kumar gonna shake can you please put in your questions into the q a window okay so the next question is from bharat sharma this question is there are intangible impact on organization due to poor quality mainly the image perception in the market and losing market share any reason why we are not discussing these aspects well those those are the consequences but uh those conscious it's most of us it's mostly because of perception and but what is under your control is what you should be focusing on to getting the things right making sure that the results are accurate and reproducible and reliable and they are delivered on time taking part in external quality assurance program and getting 100 score indicates that and then that has to be done by any lab worker not the best when you get qa samples you do not assign and assign them to the best technician only the aim is that they are to be treated as ordinary samples and if you get them right every time then there's the possibility that you're doing something right wonderful um okay so there is a lot of there are a lot of people who are asking for the presentation uh please don't worry we will share a copy of this presentation and we'll put it up on our website which is kiwani.com and you can download it from there and there's also a beautiful write-up which ashok has shared with us so we will provide that also along with the presentation um so just follow us on our web linkedin and then you will get to know when we are posting it and then you can download it okay back to the questions um from guru raj they say what is the methodology for training the trainer see uh normally it is there it depends upon the test that you're using and uh and there are three steps to it one is that an expert should show the trainer how it is done then you should watch the trainer demonstrate to you how it is done and finally the trainer is left to it and that is where you get the feedback and make correction till you are satisfied after that the trainer is left to train others so a three step process wherever whatever is the technique to be to be used one is that a standard operating procedure must be written down it should not be in the mind of the expert it should be written down in language that they can understand sops are available and they can be used but they must be they must be made suitable to your own working and as written sops must be available at the site of testing so that a person is not supposed to remember all the steps you are you are at liberty to review and revise the standard operating procedure and they should be available whether in electronic or written form at the time at the site where the test is being done that way you will ensure that persons all are falling and they should not be any discrepancy between sop what is written in sop and what is being done and this this is what has to be trained to the trainer and the trouble with india is that we are full of persons who have 101 shortcuts i think in the laboratory we should encourage them to give their suggestions and we should listen to their suggestions but all work should be ing to sops and if their suggestions are incorporated into the sop then they should be rewarded but the chained sop then everybody should follow so just make sure that everybody does if you have to get reputable result nobody no matter who is doing the work whether it is 8 8 am or 8 pm 2 pm or 2 am if the results are going to be similar and reproducible then you have to have same methods and you have to test their competency of every individual in able to complement to comprehend what is required and to implement the first the test that is entrusted to them right so listen to the shortcuts but make it a part of the sop yes if it is useful input is useful all right so moving on to pin to batacharya this is a very practical question sometimes it is not possible for small companies to follow six sigma principles then how would they prevent failures and maintain the quality i think it goes to the root of saying is six sigma only for large companies does it not apply to the small companies well it depends upon what uh see maybe small companies will do small things but they'll have their in their involvement if the quality standards cannot change just because one is an international company and the other is a small homegrown camp company would you like to get an injection from an untrained person if you break down every activity as a process then just make sure the processes that you do are done the right way and if there is no variation then you will be meet you would have less chances of making mistakes wonderful okay so there were a few questions in the chat i'm just pick those up before i come back to the q and a panel um one question is from savitra ks technology is developing and we have a lot of competition in the market so given all of this how do we assure quality that's the question from savita quality is inbuilt into the new systems they have now the new instruments will read the barcode we'll know what tests have to be performed we'll look at the barcode of the the reagent and will not use expired date so all that is already built up that would mean that human people humans have to stress more on pre-analytical which is the most variable and in post-analytical to make sure that the report reaches the right person in a manner in which he can understand and interpret if he cannot interpret the results then that means that is still of poor quality you have to make sure that a person knows what is to be done once the report reaches him and that's where pre-pre-analytical about what tests are required what is the preparation that a person has to undergo before this test is done what what would be the time that the test would be taken i do remember about tsh there was one person who would tsh has a diurnal variation so if you collect the sample at eight o'clock you'll have a different value if you collect at 12 o'clock you'll have different value so in a healthy individual and if a person is sick then psh that is thyroid stimulating hormone can go right out of the window so if you want reliability and you don't want a person fighting with you you need to make sure that the sample is corrected at the right time so you need to pay attention to detail quality cannot come without paying attention to detail great so um the next one is from hope i'm just pronouncing a name right um the graph shows high quality requires high cost how to reduce cost ensuring high quality no uh the cost of running a lab consists of a prim of preventive cost appraisal cost and failure cost it is failure cost which eats up most of the budget and it cannot be budgeted for on the other hand while your cost for prevention is very low if you ask persons have they been accredited are they taking part in quality assurance program are they are they are they running quality controls every day are they bracketing their clinical work with quality control most of them will say no so they're cutting corners at the wrong place and then when they have failures then they're crying for high cost you have to invest in prevention if you invest in prevention then you do not have to cry for high cost of failures failures will not occur failures occur because you have not taken the right preventive steps if you take the right preventive steps and that cost money i'm not saying it's they don't cut money but you will be able to charge five times more from the patient but failure will cost will eat up all the profits if you do not invest in prevention it's being penny wise and pound foolish by not investing into quality yes okay next one is from ramesh kumar bana shakran could you please give me a definition of redo or re-tests redo or re-test is when you suspect that something has gone wrong and you you are re-testing which is not required if it is not required and you are re-testing that means you are you are wasting your resources as well as time redraw would be if the sample is if there's something wrong with the sample either it is humanized or it has got contaminated or it is lipoic or the quality is not sufficient okay from baby um indra all the factors affecting the quality of result is applicable to all labs so being a foot testing lab manager i came across all these one way or the other okay i don't think there is a question it's more of a comprehensive thanks sir oh so let me extend that saying that is it applicable only to the health care of the diagnostic setup or it sort of fans into all other laboratories i think quality management system applies to all all walks of and they would be specific instances which would be different but wherever there is a process you would have the same phases going into the play okay right the next one is from doghang how does the calibration cost affect the quality could you explain more oh uh see um i've had this a number of times in many of the labs that i've worked and it would be that if the test which is used is uh not a frequent test and normally it's been recommended that you do calibration every every three weeks or so so in calibration you would have uh you would so you spend time in doing calibration and then you find that there's no sample which has come but if after two or three weeks a sample comes then you test the the results are out of range then you do calibration once again and then so that would mean that the lab must decide what should be the frequency of what are the tests that they are doing frequently frequently and outsource those which are rare test rather than based on calibration another problem i noticed was that in one of the labs that we had one of the junior most technician would come and open the lab and he would then do the test he would run the quality control when he finds that the quality control is out of out of range then he will do calibration so for say 10 tests he had done calibration about 20 times so it is the calibration is essential step to calibrate the the system but it should be done at whenever the time has been indicated by the manufacturer and you should support that along with daily qcs and it's also best to do qc before you start clinical testing and do qc after you have you finish for the day so that if both qcs are within normal range then all your results are reliable many places they do you see in the morning and it's only in the next morning will they know that the qc is out and then they will have to retrace all the tests that have been done during the day to find out where the where the instrument went out of range so clinical testing should be bracketed with quality control testing before and after all right um so there are two user choice questions because both are nectar neck in terms of getting their reports let me pick up the first one from dm charms the question is in case of quality cost sometimes promoters are not ready to invest convince them in this case i guess if you do the do the calculation of in the paper that i'll the handout that i'm giving out that gives you on how to calculate the cost and then you say if you a failure cost is this much appraisal cost is this appraisal cost normally should come to about 10 to 20 percent of the total budget and then a a preventive cost should be again 20 so 20 for uh preventive cost 20 for appraisal cost and that cost will make sure that there is no place for failure at the moment appraisal preventive cost is one of one to five percent ten percent is the appraisal cost the rest is all eaten up by failure failure is more expensive than conventional failure is more expensive okay the next is a choice question from chandrashekaran regarding the third party frequent outlier occurs without establishing in-house lab um so the cost of quality increases how to address this is the manufacturer's qt run in parallel acceptable i think the question is more in terms of if there is a third party um establishment doing these lab related activities how to establish and control the quality measures yes and but see even if it's third party then third party will be giving to hundreds of users if you take part in cap college of american pathologist program they have about 10 000 participants so if and they would then analyze ing to the instrument that you're using one i used to use i used to indicate that if the instrument if they have four or five instrument and the instrument we are using is not one of the instrument listed then either we are a thought leader or we're doing something wrong if the world is using uh and we have good lab cap quality control costs a lot so uh if you are willing to if you are aiming for that kind of quality you would be using uh instruments which would match which will give you that kind of reliability and if your instrument doesn't match into one of the five that are listed then there is a problem somewhere so as it is that means you have chosen an instrument which has not been proven to be as reliable as the others so the problem might start with that and then you have to have your lab mean once you have your lab mean then you would be able to see whether your results are matching or not and where you fit in would be another from instrument to instrument there is some some variation so that needs to be taken care of all right so the next question is from more like kareem kumara and the question is is it advisable to use expired reagents after validation expired reagents can only be used for training purposes for trials etc but not for patient care you see there are many factors which go into giving the expiry date of the agent just because it is it's working fine now doesn't mean that it will continue what normally happens there are various parameters and we're not testing all the parameters so i think we should not falsely this is uh false attempts to see that uh just because it has worked fine just because uh the results are within range the expired uh expiry date can be extended no you do not extend the expiry date and you must have the discipline to use the reagents within the expiry date for clinical purposes for training for others that is when you're showing them how it is done for demonstration purposes you can but it should be clearly marked and should not be in the same refrigerator as the reagents to be used for clinical purposes okay so you can still save on some cost by using them for trading okay um question is there is often confusion between corrective and preventive action once an error has occurred can you take preventive action for preventing recurrence no that is the then you're doing correction once the once the error has occurred then it is a pre it is a correct correction of the error that has occurred so then you have to do root cause analysis on why the why uh why the error occurred and it might lead you to a root cause which you need to address okay great so we've got a few minutes left on the clock um i'll just pick up the last two questions and uh before we say uh goodbye to your show the first one is from coccoli banerjee and the question is is risk assessment regarding lab analysis can be considered under prevented cost yes i think that is when you set up the lab then you do risk analysis of where are the risks what are the chances of of error occurring what controls need to be that is of setting up the processes so that will be part of of preventive cost and uh in the west i think uh instead of having same qc for everything they have they've had the qcs change ing to the risk assessment if the if the test is so robust that it will give you the same results every time then you can decrease the number of qc's that you run while if the result is variable then it should be controlled by frequent pc [Music] okay the last question for you uh is from sumatri mulliga any tips on improving the accountability of technical staff in quality improvement of a laboratory i see a smile on your face i think it's motivation because ultimately um [Music] sumidi is we know each other for some time and her husband and i we were colleagues and um and she's a very very sincere worker but she works in a government setup i work in a private setup the difference of course is motivation i think if you mo if you motivate the if you can find the mo what motivates the staff and i agree that in india money seems to be a an important motivation not punitive motivation if you can give them if they perform well and you give them some bonus then that's a good motivation but sometimes is the ego also which is important so i guess what is required is to work on to find out what motivates the individual and to see how you can you can pump them up to do the right thing right but ensuring that they stick to the sops will make sure that that that results are right okay that's splendid so um i think there are a few more questions that has come in but um given the positive time we'll take it up uh offline um but um ashok i just wanted to let you know that there are so many messages thanking you for a wonderful presentation and people from all over the world i didn't want to you know sort of tell that to you every time it was coming in because it kept uh pinging thank you thank you thank you thank you thank you i didn't want to be the train of thoughts but i think you should be aware of it there are so many people around the world who are uh absolutely thankful for what you have delivered today thank you yeah and um so from uh kiwanis all of us here and from perspectives this is a great addition to our thought leader initiative this is going to be staying on youtube serving a lot of people for a long time to come so thank you so much for being with us it was great having you and great having all the participants there have been many requests for the presentations uh guys folks not with the presentation you will also get a copy of a beautiful write-up ashok is done regarding uh cost and quality we will be putting it up on our website so that you can download it just follow us on a social media channel and then you will get to know when we are publishing it um with that thank you very much for making the time to join us today we will see you in the next edition of perspectives the portland initiative by kiwani thank you ashok and thank you everyone yes bye